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Journal of Ethnic & Cultural Diversity in Social Work
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From Cultural Competence to Cultural
Consciousness: Transitioning to a Critical
Approach to Working Across Differences in Social
Work
Corry Azzopardi & Ted McNeill
To cite this article: Corry Azzopardi & Ted McNeill (2016)
From Cultural Competence to
Cultural Consciousness: Transitioning to a Critical Approach to
Working Across Differences
in Social Work, Journal of Ethnic & Cultural Diversity in Social
Work, 25:4, 282-299, DOI:
10.1080/15313204.2016.1206494
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From Cultural Competence to Cultural Consciousness:
Transitioning to a Critical Approach to Working Across
Differences in Social Work
Corry Azzopardia and Ted McNeillb

aThe Hospital for Sick Children, Division of Pediatric
Medicine, Department of Social Work, Toronto,
Ontario, Canada; bUniversity of Toronto, Factor-Inwentash
Faculty of Social Work, Toronto, Ontario,
Canada
ABSTRACT
Driven by increasing cultural diversity and growing inequities
in
health and social outcomes, cross-cultural competence has
become a fundamental dimension of effective and ethical social
work practice. It has assumed aprominent discourse in social
work
education, scholarship, professional practice, codes of ethics,
and
organizational policy; however, how one defines, acquires,
applies, and evaluates cultural competencies continue to be
issues of debate. Grounded in a postmodern epistemic frame,
an integrated model of critical cultural consciousness for
working
across differences in social work is proposed and implications
for
micro, mezzo, and macro levels of practice are discussed.
KEYWORDS
Cultural competence; culture
and diversity; social work
education; social work
practice
Driven by increasing cultural diversity across North America
and growing inequi-
ties in health and social outcomes among minority groups,
cross-cultural compe-
tence has become a fundamental dimension of effective and
ethical social work

practice. The concept of cultural competence has assumed a
prominent discourse
in social work education, scholarship, professional practice,
codes of ethics, and
organizational policy. How one defines, acquires, applies, and
evaluates cultural
competencies, however, continue to be issues of debate in the
social work profes-
sion. This article reviews selected bodies of theoretical and
empirical literature
examining cultural competence in social work and related
disciplines, including
conceptual underpinnings, practice approaches, and
controversies. Grounded in a
postmodern epistemic frame, we propose an integrated model of
critical cultural
consciousness for working effectively across differences in
social work and discuss
implications for micro, mezzo, and macro levels of practice.
Culture and diversity: framing the constructs
The meanings ascribed to the terms culture and diversity have
evolved over
time and have held different connotations and significance in
the social work
CONTACT Corry Azzopardi [email protected] The Hospital for
Sick Children, Division of Pediatric
Medicine, Department of Social Work, 555 University Avenue,
Toronto, Ontario, Canada, M5G 1X8.
JOURNAL OF ETHNIC & CULTURAL DIVERSITY IN
SOCIAL WORK
2016, VOL. 25, NO. 4, 282–299
http://dx.doi.org/10.1080/15313204.2016.1206494

© 2016 Taylor & Francis
profession at various points in history (Kohli, Huber, & Faul,
2010). Culture,
from our perspective, is understood as the shared identity or
identities of a
group of people based on common traits, customs, values,
norms, and
patterns of behavior that are socially transmitted and highly
influential in
shaping beliefs, experiences, and worldviews. Based in
anthropological and
ethnographic studies and informed by a modernist perspective,
the term
culture was traditionally narrowly limited to the one-
dimensional character-
istics of race and ethnicity shared by members of a specific
group.
Current conceptualizations of human diversity extend beyond
outward
manifestations of culture such as race, religious observances, or
material arti-
facts to include subjective experiences associated with the
multiple social loca-
tions in which individuals are immersed, including age, gender,
sexual
orientation, (dis)ability, socioeconomic status, geography, and
political affilia-
tion, among other diversities. Through a contemporary
postmodern lens,
culture and diversity are viewed as individually and socially
constructed phe-

nomena that are ever-evolving (Dean, 2001). From this
perspective, diverse
groups are not homogeneous in nature despite sharing some
common history,
attributes, or practices. Individuals are understood to have
intersecting and
fluid identities, with wide variation between and within
different groups.
Cultural competence in social work: significance and
controversies
There have been many conceptual definitions of cultural
competence and
related terms such as multicultural practice proposed in the
literature (Boyle
& Springer, 2001). Kohli and colleagues (2010) chronicle the
history of the
inclusion of diversity content in social work education, from the
assimilation
and melting pot paradigm of the 1950s to the social
constructionist ethno-
cultural framework of the past decade. It remains a rather
complex, elusive,
and evolving construct. In its simplest form, cultural
competence can be
understood as an ongoing process whereby one gains awareness
of, and
appreciation for, cultural diversity and an ability to work
sensitively, respect-
fully, and proficiently with those from diverse backgrounds. In
one of the
most frequently cited definitions across disciplines, Cross,
Bazron, Dennis,
and Isaacs (1989) describe cultural competence as “a set of
congruent beha-

viors, attitudes and policies that come together in a system or
agency or
among professionals that enable effective interactions in a
cross-cultural
framework” (p. 4). An important feature of this
conceptualization is its
emphasis on competencies across personal, organizational, and
systemic
levels, as opposed to simply a characteristic of the individual.
There has been a growing appreciation for the complexity of
cultural com-
petence, including the trajectory of knowledge development and
integration of
critical knowledge for practice. Historically limited to racial
and ethnic mino-
rities, the concept of culturally competent practice has more
recently been
SOCIAL WORK 283
applied to all individuals of diverse backgrounds. The
ideological underpin-
nings and logistical shortcomings of cultural competence have
been the subject
of considerable debate. Its controversies, contradictions, and
barriers have been
discussed extensively in the literature (Ben-Ari & Strier, 2010;
Dean, 2001;
Furlong & Wight, 2011; Harrison & Turner, 2011; Iglehart &
Becerra, 2007;
Johnson & Munch, 2009). Based on the assumption that cultural
knowledge

translates into competent practice, the term competence is
criticized for imply-
ing that a tangible set of skills and behaviors can be achieved
and measured.
Williams (2006) notes the problematic emphasis on technique in
the absence of
a coherent theoretical foundation, which is critical to informing
the rationale
for why certain practice approaches are believed to be more or
less effective
than others, as well as providing the groundwork for evaluating
their efficacy.
Cultural competence frameworks have also been challenged for
their
erroneous assumption that clinicians are from the dominant
culture
(Sakamoto, 2007b), disregard of immense within-group
diversities (Tsang,
Bogo, & George, 2003), and situating competence as a static
characteristic of
the clinician (Lee, 2010). Perhaps the greatest shortcoming of
much of the
literature on cultural competence lies in its apolitical stance,
weak or absent
analysis of power relations, promotion of othering, and
inadequate approach
to addressing oppression at systemic and structural levels
(Abrams & Moio,
2009; Sakamoto, 2007b). Daniels (2008) calls for a paradigm
shift in social
work education to embrace a more critical understanding of the
experiences
of oppressed individuals and groups.
Irrespective of these conceptual and practical tensions,

considerable attention
continues to be given to cultural competence in the burgeoning
theoretical and
empirical literature, education curricula, and organizational
policies and prac-
tice standards. Furlong andWight (2011), for instance, discuss
the practical and
rhetorical appeal of cultural competence, despite incoherence
and ambiguities
in definition and operation. This sentiment is echoed by
Williams (2006), who
asserts that, notwithstanding poorly understood competencies
and applications,
cultural competence “demands that we practice with skills,
attitudes, and values
that will make us effective and adequate in service provision to
clients who
originate from a variety of cultural backgrounds” (p. 210).
Culturally competent practice models: strengths and
shortcomings
A number of approaches to culturally responsive practice have
developed
over time. Grounded in a modernist paradigm, the cultural
literacy model
was the first broadly applied framework (Dyche & Zayas,
1995). Based on the
assumption that culture is knowable, this approach emphasized
learning
about the shared history, traits, and practices of particular
cultural groups
and applying culturally specific interventions. Rooted in
anthropology and
ethnography, the cultural literacy model fit with early
definitions of culture

284 C. AZZOPARDI AND T. McNEILL
as a static and monolithic construct, thus neglecting the degree
of accultura-
tion and sociocultural realities of multiple intersecting
identities. It has been
criticized for its impracticality, reductionist approach, attention
to the
abstract over the experiential, and potential for
overgeneralization and
stereotyping (Ben-Ari & Strier, 2010; Dyche & Zayas, 1995;
Tsang & Bogo,
1997). The notion that one can truly know another’s culture or
be an expert
in the cultures (and subcultures) of others has been challenged
as unrealistic
and simplistic (Dean, 2001). Furthermore, a cornerstone of early
approaches
to cultural competence was a celebration of differences relating
to distinct
cultural histories and traditions. There were, and continue to be,
good
reasons to celebrate differences; however, this lens can
inherently obscure
other critical dimensions of experience such as racism and
discrimination.
Social work has historically adopted either a cultural deficit
approach or a
cultural relativist approach to practice, both of which can be
problematic
(Barn, 2007; Chand, 2008). A deficit perspective is criticized
for pathologiz-

ing cultural beliefs and practices perceived as deficient,
resulting in interven-
tions that are overly intrusive or unnecessarily interventionist.
A relativistic
perspective, on the other hand, is criticized for viewing all
cultural practices,
including those that are potentially harmful, as equally valid,
resulting in
interventions that are too weak or hesitant. The challenge comes
in striking a
fair balance between the two ends of the spectrum. Healy (2007)
suggests that
social workers are likely to find a midpoint that may shift in
one direction or
the other depending on client circumstances; however, cultural
relativity
should never be used as a rationale for violating human rights.
Although several cultural competence frameworks have been
proposed in
social work practice and academia, no consensus appears to
have been
reached in the profession thus far. In their synthesis of the
cultural compe-
tence literature, Kohli and colleagues (2010) conclude that most
approaches
share some basic assumptions, including the premise that reality
is socially
constructed, diverse worldviews must be appreciated, multiple
realities shape
individual personalities, and diversity education has a positive
effect on
developing cultural competencies. Este (2007) also highlights
several key
themes emerging from the literature describing the building
blocks for

culturally competent social work practice, including a specific
knowledge
base about diversity and oppression, a lifelong process of
learning about
the worldviews of cultural groups, strong communication skills,
a capacity
for empathy, and a congruent intrinsic value base.
Informed by a postmodern frame, Sue, Ivey, and Pedersen’s
(1996) theory
of multicultural counseling and therapy is possibly one of the
most influen-
tial frameworks for delineating the development of cultural
competence in
the helping professions. This approach views cultural
competence as an
active and ongoing process and proposes a 3-by-3 matrix
consisting of
three characteristics of cross-cultural competencies: (a)
counselor’s awareness
SOCIAL WORK 285
of his or her own assumptions, values, and biases, (b)
counselor’s awareness
of the client’s worldview, and (c) culturally appropriate
interventions—all of
which develop across three dimensions: (a) knowledge, (b)
beliefs and atti-
tudes, and (c) skills. An understanding of macro-systemic
factors was more
strongly incorporated in later versions of the framework (Sue &
Sue, 2013). A

major limitation of this theory, however, is its culture-specific
focus as
opposed to a broader worldview. Nevertheless, the core
dimensions of
knowledge, awareness, and skills are foundational to most
frameworks and
standards for culturally attuned practice (Jackson & Samuels,
2011; National
Association of Social Workers [NASW], 2001, 2007).
In social work, cultural competence models are increasingly
informed by
social-ecological theory and target micro-, mezzo-, and macro-
level actions
and results (Simmons, Diaz, Jackson, & Takahashi, 2008). With
their added
emphasis on the impact of social injustices and oppressive
power relations
and the goal of social change through multilevel practice, some
of the cultural
competence models proposed in the social work literature have
addressed the
shortcomings of psychologically oriented frameworks. For
instance, George
and Tsang (1999) examine the social construction of diversity
and address
the intersectionality of oppressions in their social
constructionist approach to
cultural competence; Laird (2008) and Sakamoto (2007a, 2007b)
advocate for
the infusion of anti-oppressive principles into culturally
competent practice
models; and Saleebey (2012) focuses on client strengths rather
than problems
with the goal of promoting empowerment. Fong (2004)
integrates each of

these elements in her contextual approach to culturally
competent social
work practice using an ecological framework. The person-in-
environment
focus of ecological theories, the cornerstone of social work
practice, encom-
passes both individual and environmental factors when
assessing problems
and finding solutions with clients from diverse backgrounds
(Haynes &
Singh, 1992). Moreover, the values and ethics underpinning
social work
practice have been recognized as providing a foundation for
understanding
and appreciating culture and diversity (Hugman, 2013).
Addressing the power imbalances that shape worker-client
dynamics, the
construct of cultural humility has emerged as an alternative
conceptualiza-
tion of cultural competence that underscores authenticity,
respect, and hum-
bleness in helping relationships. Fisher-Borne, Cain, and Martin
(2015)
describe the core interconnected elements of cultural humility
as institutional
and individual accountability, life-long learning and critical
reflection, and
mitigation of power differentials. Characterized by an “other-
oriented” inter-
personal stance, cultural humility has been shown to be
positively correlated
with a strong working alliance and improvements in therapy
(Hook, Davis,
Owen, Worthington, & Utsey, 2013).

Toward a critical model for working across differences in social
work
practice
Integrating cultural competence and social work practice in a
coherent and
clinically grounded way poses a continuing challenge in the
field and conse-
quently, a gap in the literature (Lee, 2010). While there appears
to be some
consensus regarding the broad constructs of what constitutes
cultural com-
petence, specific practice components have not been firmly
established. Thus,
building upon the strengths and mitigating the implicit and
explicit short-
comings identified in the literature, we propose an integrated
conceptual
framework for culturally responsive social work practice.
Cultural competence has been defined in various ways, but at its
core is
the ability to work effectively across differences. Given that
individuals
interpret their world in complex and ultimately unique ways, we
argue that
social workers are always working across differences,
regardless of the extent
to which they share a common cultural heritage or social
location with their
clients. Recognition of this fundamental reality of practice is
reflected in the

proposed model. Given the power of language in shaping social
work dis-
course, we have replaced the term competence with the
construct of con-
sciousness. We agree with others (e.g., Dean, 2001) that one can
never
unequivocally achieve competence simply through the
acquisition of cultural
knowledge and skills. That being said, maintaining a
continuous, mindful
awareness of culture and diversity, including the complex ways
in which they
construct meaning and experience, promotes effective and
ethical practice.
We view cultural consciousness, therefore, as an ongoing and
dynamic
developmental process with no endpoint—one that requires
active, critical,
and purposeful engagement on the part of the social worker
entering the
helping relationship.
Our framework offers an integrated and multilevel approach to
culturally
conscious practice and advances knowledge by addressing the
limitations of
existing conceptual models in several important ways. First, it
is grounded in
a strong epistemological and theoretical foundation. Second, it
adopts a
multidimensional view of culture that extends beyond race and
ethnicity to
include multiple, intersecting, and shifting identities, thereby
not limiting its
utility to visible minorities. Third, it offers analyses of
asymmetrical power

relations contributing to cultural alterity. Fourth, it can be
infused into
multilevel social work practice across micro, mezzo, and macro
concentra-
tions. Fifth, the model identifies specific clinical skills and
provides a con-
ceptual framework focusing on cognitive and affective domains
that can be
applied to generalist social work practice. Sixth, it can be
widely and effec-
tively utilized by social workers from both minority and
dominant cultures
working with clients from both minority and dominant cultures.
And finally,
cultural consciousness is conceptualized not only at the level of
the individual
SOCIAL WORK 287
social worker, but also at the broader level of the organization,
recognizing
that systemic support is crucial to delivering culturally
responsive services.
With knowledge, skills, and attitudes as overarching
dimensions, the core
components of the proposed model of critical cultural
consciousness in social
work are delineated across four fundamental domains: (a)
evidence-based
knowledge, (b) conceptual framework for practice, (c)
intervention strategies,
and (d) critical self-awareness. Although each element is

discussed next in a
sequential manner, together they provide context for one
another and inter-
act in reciprocal ways.
Evidence-based knowledge
Specialized knowledge in a variety of substantive domains
supports an
evidence-based approach to working competently across
differences and
fosters critical thinking. The knowledge relevant to informing
practice will
vary depending on the unique cultural background, social
locations, and
situational context of each diverse individual. While reliance on
“knowing”
culture has been critiqued as reductive and promoting
stereotyped assess-
ments, we argue that evidence-based knowledge about culture
and diversity
can be a valuable component of social work practice, when
applied appro-
priately. Knowledge generated through quantitative and
qualitative research,
including community- and arts-based designs for example, is
ideally suited to
inform practice. Opportunities to critique methodological rigor,
potential
sources of Eurocentric bias, and knowledge claims can remedy
some of the
implicit tensions between cultural competence and evidence-
based
approaches, which sometimes privilege certain “ways of
knowing” over
others (Kirmayer, 2012).

The experiences of individuals, however, are unlikely to mirror
exactly the
collective experience of groups. For this reason, empirical
knowledge must be
considered tentative and neither generalizable nor transferable
in its applica-
tion at the level of a unique individual, family, or group.
Consistent with
Laird’s (1998) concept of “informed not-knowing,” knowledge
should be
approached with an open mind, while maintaining a capacity to
suspend
such knowledge to mitigate against stereotypes and false
assumptions. To this
end, group-based knowledge can be helpful to sensitize social
workers to
potential cultural practices and experiences of individuals
without essentia-
lizing them. This is a subtle yet important distinction. An
attitude of
“respectful curiosity” (Dyche & Zayas, 1995) augments
simultaneous efforts
to understand unique variations through a process of empathic
confirmation
and learning from individual clients, who are the real experts
about their
lives.
We highlight three broad knowledge domains next, which we
purport to
be key elements of evidence-based cultural consciousness in
social work.

Discrimination and inequality as social injustices
The supposed problem with difference, as pointed out by Cooke
(1999), is
that some people are discriminated against simply because they
are different
from the majority or dominant culture. As human beings, we
seem to have
an infinite capacity to dichotomize others as “us” or “them”
depending on
how we perceive their similarities or differences. Consequently,
an indivi-
dual’s experiences and opportunities in life are shaped by the
manner in
which he or she is potentially subordinated (or privileged) in
society based
on dimensions of diverse identities. Those who are regarded as
different from
dominant groups according to socially prescribed power
hierarchies are more
likely to experience discrimination and adverse outcomes
(Wilkinson &
Pickett, 2009). This is the profound reality that transforms the
issue of
being different into one of potential social injustice and thus
constitutes
essential knowledge for practice.
Evidence-based knowledge from around the world has shown
that
inequality has reached a critical point. The size of the gap
between the rich
and the poor has been consistently correlated with virtually any
health,
socioeconomic, or social outcome (Wilkinson & Pickett, 2009).

For example,
evidence suggests that socially marginalized groups experience
multiple
forms of interpersonal and systemic discrimination in health
care, which
impede access to health services and result in greater health
disparities
(Betancourt, Green, Carrillo, & Ananeh-Firempong, 2003;
Mikkonen &
Raphael, 2010; Raphael, 2009).
History, colonialism, and neoliberal ideology
Working with others takes place within a particular historical,
social, poli-
tical, and economic context. In Western societies, the past three
decades have
witnessed a vast expansion in cultural diversity. Knowledge
about specific
cultures is an important starting point for cultivating cultural
sensitivity and
insight into the social realities of diverse groups. For instance,
group-based
historical knowledge about the devastating impact of
colonialism on
Indigenous populations can raise awareness of potential issues
manifesting
at the personal level but originating at the societal level.
Knowledge of the
multifaceted ways in which power-based oppression,
marginalization, and
systemic discrimination can affect health, well-being, and
service delivery is
an essential component of critical social work practice with
diverse
populations.

The broader context of capitalism, globalization, and
neoliberalism
emphasizes individual (over social) responsibility and shrouds
the structural
obstacles that disproportionately impact diverse individuals and
groups
(Coburn, 2010). The global shift toward smaller government,
deregulation,
lower taxes, laissez-faire capitalism, and the consequent
degradation of social
welfare programs and services contributes to personal
hardships. While
SOCIAL WORK 289
social and economic policies shaped by neoliberal ideology
impact all indi-
viduals to some extent, diverse populations such as racialized
minorities, new
immigrants, and those living in poverty are often more severely
affected. This
knowledge is inherently political and can inform advocacy
efforts for broader
social change.
Postmodernism, multiple identities, and intersectionalities
A postmodernist paradigm recognizes the continuously changing
nature of
experience and embraces multiple personal and contextual
realities, unique
narratives, and subjective interpretations. With an appreciation
for multiple
truths and sources of knowledge, a postmodern perspective

views all cultural
beliefs, practices, and worldviews as valid. Individuals may
identify with a
variety of diverse characteristics and social locations that
contribute to them
being perceived as different, thereby increasing their risk for
various forms of
discrimination. The concept of intersectionality is used to
capture this com-
plex interplay among multiple identities and sites of possible
oppression (and
privilege).
A postmodern orientation promotes a conceptual shift from
situating the
social worker as expert, embraces uncertainty, and places
emphasis on
learning with and from the client. Representing and speaking
for the
“other” can be hazardous given the (unintentional) potential for
harm and
disempowerment. To reflect the relational focus and dynamics
of clinical
social work practice, Lee (2010) envisions cross-cultural
competencies as
fluid processes that vary over time with each unique individual.
This revi-
sioning expands the construct of cross-cultural work beyond a
static char-
acteristic of the social work clinician to encompass the dynamic
interactions
between dyads within a therapeutic relationship; in other words,
from a one-
person psychology to a two-person psychology. This
interpersonal process is
both iterative and reciprocal, reflecting their shared history and

interaction.
Highlighting the challenges involved in maintaining positive
engagement and
responsiveness in therapeutic dialogue across cultures, Lee and
Horvath’s
(2014) work illustrates the importance of focusing on moment-
to-moment
interactions in cross-cultural clinical practice.
Conceptual framework for practice
In addition to the empirical knowledge domains just described,
working
effectively across differences requires a broad yet clearly
articulated concep-
tual framework to integrate components of practice. As social
workers, we
function in positions of power and are “brokers of reality”
(McNeill, 2006);
that is, we are in privileged positions to make judgments about
the behaviors
and actions of our clients. The lenses through which we
understand the
experiences of others are of central importance. For example, if
we are
oriented solely to a personal growth approach, we may perceive
clients as
struggling with lifestyle choices, in which case we are likely to
formulate the
presenting issues as “private troubles” with a corresponding
clinical goal of

facilitating more individual responsibility. This approach may
obscure the
broader structural forces at play within the social environment
that operate
to marginalize and oppress. Alternatively, if we identify
exclusively with a
structural approach, we may overlook important personal
variables while
concentrating on societal power imbalances beyond the control
of the
individual.
Although it is not feasible to explore the full range of theories
and
conceptual models that may contribute to an overall framework
for culturally
competent practice, we highlight key complementary approaches
that may be
particularly helpful in bridging the cultural divide in social
work practice.
Ecological and strengths-based orientations
Ecological systems theory, with its emphasis on the reciprocal
interplay of
factors across micro, mezzo, and macro systems, provides an
ideal framework
for integrating important considerations at multiple levels of the
social
ecology (Bronfrenbrenner, 1979). At the micro level, attention
is drawn to
the emotions, behaviors, cognitions, attributions, and
relationships that
shape and reflect individual experience, and may be suitable
targets for
clinical interventions to promote personal agency, self-efficacy,
and psycho-

logical welfare. By contrast, macro-level analysis provides a
means of identi-
fying powerful structural forces that impact individuals such as
the broad
social determinants of health (e.g., toxic effects of poverty and
social exclu-
sion on health and well-being), combined with restricted
availability of social
welfare programs consequent to neoliberal restructuring.
Recognizing the
reciprocity of factors across ecological systems contributes to a
broader
understanding and scope of practice to address multilevel
problems.
A strengths-based orientation is an important component of
social work
practice with clients from diverse communities who experience
personal
blame for the challenges they face (Larson, 2008; Saleebey,
2012). A strengths
perspective guards against pathologizing individuals by shifting
attention
from deficits to assets. Moreover, a resilience model that
identifies both
risk and protective factors at all levels of social ecology
complements a
strengths-based approach while simultaneously validating the
obstacles at
play. Areas of risk and resilience are understood as subject to
interpretation.
Attributed meanings are personally and socially constructed and
are part of
the bedrock of human experience (Wakefield, 1995).
Critical approaches

Critical theories such as feminism and political economy offer
additional
necessary frameworks for understanding diversity, oppression,
and aspects of
SOCIAL WORK 291
experience within a social context. Critical approaches to
practice help to
expose sociocultural and political processes that reinforce
embedded power
asymmetries that shape the lived experiences, social exclusion,
and material
deprivation of marginalized groups.
Together, these complementary approaches comprise
components of a
conceptual framework that recognizes individual qualities as
well as environ-
mental factors that are the source of many hardships affecting
diverse
individuals and communities. It is not our intent to be
prescriptive about
specific approaches but to identify the importance of including
a critical lens
as part of a multi-theoretical framework.
Intervention strategies
Through the integration of evidence-based knowledge and an
overall con-
ceptual framework that promotes the use of various lenses for
understanding

a client’s circumstances, social workers can apply a range of
culturally
responsive intervention strategies, including anti-oppressive
practices at clin-
ical, community, and policy levels. It is beyond the scope of
this article to
provide a full account of all potentially relevant interventions.
Nonetheless,
we propose the following as complementary dimensions of
social work
practice that are helpful in working effectively across
differences.
Individualize through clinical empathy
On a clinical level, a capacity for empathy is essential to
maximize our
understanding of others in a way that resonates both
intellectually and
emotionally. Cultural empathy requires a clinician to understand
and be
responsive to the experiences of diverse clients based on their
interpretation
of cultural data, as well as affective and communicative
processes (Ridley &
Lingle, 1996). It is a “general skill or attitude that bridges the
cultural gap
between the therapist and client, one that seeks to help
therapists to integrate
an attitude of openness with the necessary knowledge and skill
to work
successfully across cultures” (Dyche & Zayas, 2001, p. 246). In
her study
examining variables contributing to multicultural competence,
Constantine
(2001) found that clinicians who endorse higher cognitive and
affective

empathy, along with higher levels of multicultural training and
an eclectic
theoretical orientation, have better multicultural case
conceptualization skills.
The importance of empathy and compassion in culturally
competent social
work services was echoed by members of a range of oppressed
groups
(Gentlewarrior, Martin-Jearld, Skok, & Sweetser, 2008).
An empathic understanding is instrumental in facilitating cross-
cultural
engagement, trust, and ontological integrity by increasing the
likelihood that
the intersubjective co-construction of meaning and experience
approximates
the “truth” for clients. An empathic understanding therefore
individualizes
clients; that is, it differentiates them from others and reflects
their unique
aspects of identity, experience, degree of acculturation, and
shared experience
with other members of the community. As such, it is part of a
differential
approach to enable a formulation that ensures micro-level
interventions are
targeted effectively. An empathic understanding of client
strengths contri-
butes to fostering empowerment through efforts to increase
personal agency
and self-efficacy to maximize an individual’s internal locus of

control.
Deindividualize for anti-oppressive interventions
A complementary process of deindividualization is also needed
to promote an
overall formulation that includes consideration of broader
structural forces, thus
ensuring that the helping relationship is not limited to a singular
focus on
personal struggles and individual responsibility. For this reason,
an anti-
oppressive perspective and culturally conscious practice go
hand-in-hand (Ben-
Ari & Strier, 2010; Laird, 2008; Parrott, 2009; Sakamoto,
2007a, 2007b). Anti-
oppressive principles support a sociopolitical analysis of
oppressive power
dynamics that often underlie the problems faced by diverse
groups and help to
expose the Eurocentric knowledge base upon which most social
work interven-
tions are grounded (Sakamoto & Pitner, 2005). Through the
process of deindi-
vidualization and contextualization, an anti-oppressive approach
helps to
identify problems within their broader social context with the
goal of transform-
ing the power imbalances that perpetuate marginalization and
various manifes-
tations of discrimination. Thus, cultural consciousness,
informed by anti-
oppressive practice, incorporates a strong commitment to social
justice.
On an individual level, examples of anti-oppressive practice
designed to

complement clinical-level interventions include the use of a
strengths-based
approach, efforts to connect clients to necessary resources, and
individual advo-
cacy to gain access to services and navigate the system. Beyond
work at themicro
level, efforts to partner with community-based organizations to
plan for com-
munity development and advocate for changes regarding
program availability
and policy reform are valuable strategies for addressing social
context. Broad-
based systemic advocacy (i.e., efforts to ameliorate the unequal
power relations
and social conditions adversely affecting whole communities)
has the potential
advantage of mobilizing a coalition of forces to bring about
social change.
Agency and institutional context
The internal policies and service delivery standards of
institutional settings
can systemically promote or impede cultural consciousness.
Nybell and Gray
(2004) call attention to the need for “agencies to undertake an
organizational
development process that parallels the individual journey of the
worker
toward cultural competence” (p. 18). This journey begins with
organizations
embracing cultural consciousness as a strategic priority and
entrenching its
values across all aspects of its operation, from mission
statement to frontline

SOCIAL WORK 293
service delivery. This requires close examination of existing
processes and
structures that potentially constrain how well the principles of
cultural
consciousness get translated into practice. Social workers are in
a key posi-
tion to raise awareness within their organization and to work
with colleagues
in other disciplines to advance an agenda of social justice. Some
agencies may
not be ready for the language of social justice or view it as their
mandate, but
when reframed as addressing barriers and obstacles that may
complicate
recovery and compromise outcomes, it is more likely to resonate
and align
with agency priorities. Moving beyond a “feel-good celebration
of diversity”
is an important step for organizations because cultural
consciousness
includes consideration of internal attitudes, practices, and
policies that may
constitute a form of institutional discrimination.
More specifically, social workers can be advocates for
organizational indica-
tors of cultural consciousness that include a commitment to
recruiting and
retaining diverse representation on governing boards, frontline
workforce, and
leadership positions; formulating anti-oppression policies,
practices, and proce-

dures that foster a climate of respect and inclusion; arranging
opportunities for
training in cultural consciousness for staff; helping to plan for
access to linguis-
tically and culturally appropriate resources; ensuring a barrier-
free physical
space; promoting meaningful inclusion of clients as
stakeholders in decision
making; and forming partnerships with culture-specific agencies
and commu-
nities (Este, 2007; Hyde, 2004; Iglehart & Becerra, 2007;
Simmons et al., 2008).
Critical self-awareness
Fundamental to culturally conscious social work practice within
an anti-
oppressive framework is critical self-awareness about the
implications of
one’s own cultural background, social locations, preconceived
notions, ideo-
logical values, and inevitable biases. Akin to a cultural humility
framework,
ongoing reflection on how one is positioned within the
continuum of power
and its effects on practice, perceptions about clients, and the
framing of
problems and solutions is essential to this process. As social
workers, we are
in positions of relative power and have likely acted in an
oppressive manner
in some contexts (Daniels, 2008). Recognizing our potential
role in a “race
for innocence” (i.e., claiming oppressed status ourselves to
shield against
having to consider one’s own inappropriate use of power or role

as an
oppressor) is likely to be highly instructive. Exploring personal
experiences
of privilege and oppression and opening them up to critical self-
reflection,
including consideration of the complexities associated with the
intersection
of various identities and social locations in relation to our work
with clients,
will strengthen cultural consciousness and capacity for working
insightfully
across differences.
From an intersubjective perspective, Foster (1999) describes the
clinical
concept of cultural countertransference as the clinician’s
cognitive and affect-
laden beliefs and experiences existing at various levels of
consciousness,
including values and biases about different cultural groups,
practice
approaches, and theoretical orientations. She argues that
clinicians must
actively work at understanding these inevitable influences.
Although com-
plete bracketing of our preconceptions may not be feasible,
continual self-
reflexivity and mindfulness can minimize adverse effects on
practice.
Consideration of how others perceive us and the social locations
we repre-

sent is often overlooked. Regardless of our own level of self-
awareness, those
with whom we work view us through the various lenses they
bring to the
relationship. For example, those who share a similar background
may see us as
safe, or conversely, as a potential threat to their privacy within
the common
community. In other circumstances, we may be received
positively as an ally or
negatively as a representative of social authority. These
responses are not
always evident initially and although it may not be feasible or
even necessary
to address them directly, it is important to be aware that they
exist as under-
lying dynamics that affect the helping relationship.
Critical awareness should not begin and end at the level of self,
but must
extend to the institution and profession, both of which come
with authority
and preferred ways of understanding and interacting. While
recognizing
critical awareness as a crucial element of culturally conscious
practice,
Iglehart and Becerra (2007) caution against an overreliance on
worker self-
awareness and recommend expanding the focus to include
organizational
structures and processes.
Implications for social work
The proposed model of cultural consciousness reflects a
continuing shift in social

work practice to strengthen our ability to work effectively
across differences. As
articulated in curriculum policy statements and accreditation
standards, content
on cultural diversity and oppression is a required component of
social work
education in Canada (Canadian Association for Social Work
Education
[CASWE], 2008), the United States (Council on Social Work
Education
[CSWE], 2008), and elsewhere in the world. Acquiring the
complementary blend
of knowledge, skills, and attitudes to understand and appreciate
diversity is an
expectation of graduates qualified to work in social service
settings in a multi-
cultural environment. This expectation is endorsed in
professional codes of ethics
that define the intrinsic value base of social work (Canadian
Association of Social
Workers [CASW], 2005; NASW, 2008). However, there
continues to be strong
criticismof howwell cultural competence is nurtured in social
work education and
how successfully educational content translates into practical
skills (Boyle &
Springer, 2001; Laird, 2008). Parrott (2009) reports on several
studies that have
SOCIAL WORK 295
been critical of how effectively social work practice is meeting
the diverse cultural

needs of service users. The perceived lack of cultural
competence in social work
remains a recurring theme in the literature (Harrison & Turner,
2011) and will
likely persist in the face of growing social inequalities. As
evidence mounts, social
workers are in key roles tomitigate potential adverse effects
ondiverse populations.
Our ability to work effectively across differences and negotiate
cultural impasses in
the helping relationship is at the root of our potential to achieve
positive outcomes.
The core components of the proposed model are consistent with
a balanced
approach to social work practice that addresses factors
atmicro,mezzo, andmacro
levels of plural societies that shape the experiences of diverse
individuals, families,
and groups. Thus, the model aligns with the person-in-
environment and human
rights frameworks taught in most schools of social work and
incorporates a social
justice perspective. Indeed, the model aims to transform
practice from a neutral,
apolitical orientation to an enterprise for fairness and social
justice. The mechan-
isms bywhich social factors get “under the skin” to adversely
affect health andwell-
being point to the growing disintegration of the historic
nature/nurture divide
(McNeill, 2010; Raphael, 2009; Wilkinson & Pickett, 2009).
Social workers func-
tion at the boundary between individuals and their social
context and are thus in a
pivotal position to recognize the harmful impact of social

forces, particularly in
relation tominority groups. The need for cultural consciousness
is therefore at the
heart of social work practice and a key element of our
commitment to social justice.
Given that the model includes a strong focus on anti-oppressive
principles and
practices, it will appeal most to those who perceive an active
role for institutions
and governments to address structural obstacles and power
imbalances in pursuit
of a fair and just society.
Engaging in evaluation research has been challenging
historically because
of the absence of a clear definition of cultural competence and
operational
understanding of competencies. The nature of cultural
consciousness as an
ongoing developmental process, as opposed to a learnable
technique with a
finite endpoint, does not lend itself easily to empirical
validation. Despite
significant theoretical advances and an abundance of cultural
competency
educational resources available for professionals, there is
limited research
exploring the translation of cultural competence principles and
approaches
into better outcomes for diverse clients. Continued social work
research
efforts are therefore necessary to support the evidence-based
knowledge
required to refine our collective effectiveness as a discipline to
work across
differences.

Acknowledgments
The authors wish to thank the Hospital for Sick Children’s New
Immigrant Support Network
and the University of Toronto, Factor-Inwentash Faculty of
Social Work’s Bertha Rosenstadt
Fund for their financial support.
References
Abrams, L. S., & Moio, J. A. (2009). Critical race theory and
the cultural competence dilemma
in social work education. Journal of Social Work Education, 45,
245–261. doi:10.5175/
JSWE.2009.200700109
Barn, R. (2007). “Race,” ethnicity and child welfare: A fine
balancing act. British Journal of
Social Work, 37, 1425–1434. doi:10.1093/bjsw/bcm145
Ben-Ari, A., & Strier, R. (2010). Rethinking cultural
competence: What can we learn from
Levinas? British Journal of Social Work, 40, 2155–2167.
doi:10.1093/bjsw/bcp153
Betancourt, J. R., Green, A. R., Carrillo, J. E., & Ananeh-
Firempong, O. (2003). Defining cultural
competence: A practical framework for addressing racial/ethnic
disparities in health and health
care. Public Health Reports, 118, 293–302. doi:10.1016/S0033-
3549(04)50253-4

Boyle, D. P., & Springer, A. (2001). Toward a cultural
competence measure for social work
with specific populations. Journal of Ethnic and Cultural
Diversity in Social Work, 9, 53–71.
doi:10.1300/J051v09n03_03
Bronfrenbrenner, U. (1979). The ecology of human
development: Experiments by nature and
design. Cambridge, MA: Harvard University Press.
Canadian Association for Social Work Education. (2008).
CASWE standards for accreditation.
Ottawa, Canada: CASWE.
Canadian Association of Social Workers. (2005). Code of
ethics. Ottawa, Canada: CASW.
Chand, A. (2008). Every child matters? A critical review of
child welfare reforms in the
context of minority ethnic children and families. Child Abuse
Review, 17, 6–22.
doi:10.1002/(ISSN)1099-0852
Coburn, D. (2010). Health and healthcare: A political economy
perspective. In T. Bryant, D.
Raphael, & M. Rioux (Eds.), Staying alive: Critical perspectives
on health, illness, and health
care (2nd ed.). Toronto, Canada: Canadian Scholars’ Press.
Constantine, M. G. (2001). Multicultural training, theoretical
orientation, empathy, and
multicultural case conceptualization ability in counselors.
Journal of Mental Health
Counseling, 23, 357–372.

Cooke, A. L. (1999). Oppression and the workplace: A
framework for understanding.
Diversity Factor, 8, 6–11.
Council on Social Work Education. (2008). CSWE educational
policy and accreditation
standards. Retrieved from
http://www.cswe.org/File.aspx?id=13780
Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Towards
a culturally competent system
of care: A monograph on effective services for minority
children who are severely emotionally
disturbed. Washington, DC: Georgetown University Child
Development Center.
Daniels, C. L. (2008). From liberal pluralism to critical
multiculturalism: The need for a
paradigm shift in multicultural education for social work
practice in the United States.
Journal of Progressive Human Services, 19, 19–38.
Dean, R. G. (2001). The myth of cross-cultural competence.
Families in Society, 82, 623–630.
Dyche, L., & Zayas, L. H. (1995). The value of curiosity and
naiveté for the cross-cultural
psychotherapist. Family Process, 34, 389–399.
Dyche, L., & Zayas, L. H. (2001). Cross-cultural empathy and
training the contemporary
psychotherapist. Clinical Social Work Journal, 29, 245–258.
Este, D. (2007). Cultural competency and social work practice
in Canada: A retrospective
examination. Canadian Social Work Review, 24, 93–104.

Fisher-Borne, M., Cain, J. M., & Martin, S. L. (2015). From
mastery to accountability:
Cultural humility as an alternative to cultural competence.
Social Work Education, 34,
165–181.
SOCIAL WORK 297
http://dx.doi.org/10.5175/JSWE.2009.200700109
http://dx.doi.org/10.5175/JSWE.2009.200700109
http://dx.doi.org/10.1093/bjsw/bcm145
http://dx.doi.org/10.1093/bjsw/bcp153
http://dx.doi.org/10.1016/S0033-3549(04)50253-4
http://dx.doi.org/10.1300/J051v09n03%5F03
http://dx.doi.org/10.1002/(ISSN)1099-0852
http://www.cswe.org/File.aspx?id=13780
Fong, R. (2004). Culturally competent contextual social work
practice and intersectionality. In
R. Fong (Ed.), Culturally competent practice with immigrant
and refugee children and
families (pp. 310–314). New York, NY: Guilford.
Foster, R. (1999). An intersubjective approach to cross-cultural
clinical work. Smith College
Studies in Social Work, 69, 269–292.
Furlong, M., & Wight, J. (2011). Promoting “critical awareness”
and critiquing “cultural
competence”: Towards disrupting received professional
knowledges. Australian Social
Work, 64, 38–54.

Gentlewarrior, S., Martin-Jearld, A., Skok, A., & Sweetser, K.
(2008). Culturally competent
feminist social work: Listening to diverse people. Affilia, 23,
210–222.
George, U., & Tsang, A. K. T. (1999). Towards an inclusive
paradigm in social work: The
diversity framework. Indian Journal of Social Work, 60, 57–68.
Harrison, G., & Turner, R. (2011). Being a “culturally
competent” social worker: Making
sense of a murky concept in practice. British Journal of Social
Work, 41, 333–350.
Haynes, A. W., & Singh, R. N. (1992). Ethnic-sensitive social
work practice: An integrated,
ecological, and psychodynamic approach. Journal of
Multicultural Social Work, 2, 43–52.
Healy, L. M. (2007). Universalism and cultural relativism in
social work ethics. International
Social Work, 50, 11–26.
Hook, J. N., Davis, D. E., Owen, J., Worthington, E. L., Jr., &
Utsey, S. O. (2013). Cultural
humility: Measuring openness to culturally diverse clients.
Journal of Counseling
Psychology, 60, 353–366.
Hugman, R. (2013). Culture, values and ethics in social work:
Embracing diversity. New York,
NY: Routledge.
Hyde, C. (2004). Multicultural development in human services:
Challenges and solutions.

Iglehart, A. P., & Becerra, R. M. (2007). Ethnic-sensitive
practice: Contradictions and
recommendations. Journal of Ethnic and Cultural Diversity in
Jackson, K. F., & Samuels, G. M. (2011). Multiracial
competence in social work: Recommendations
for culturally attuned work with multiracial people. Social
Work, 56, 235–245.
Johnson, Y. M., & Munch, S. (2009). Fundamental
contradictions in cultural competence.
Kirmayer, L. J. (2012). Cultural competence and evidence-based
practice in mental health:
Epistemic communities and the politics of pluralism. Social
Science & Medicine, 75,
249–256.
Kohli, H. K., Huber, R., & Faul, A. C. (2010). Historical and
theoretical development of
culturally competent social work practice. Journal of Teaching
in Social Work, 30, 252–271.
Laird, J. (1998). Theorizing culture: Narrative ideas and
practice principles. In M. McGoldrick
(Ed.), Re-visioning family therapy (pp. 20–36). New York, NY:
Guilford.
Laird, S. (2008). Anti-oppressive social work: A guide for
developing cultural competence.
London, UK: Sage.
Larson, G. (2008). Anti-oppressive practice. Journal of

Progressive Human Services, 19, 39–54.
Lee, E. (2010). Revisioning cultural competencies in clinical
social work practice. Families in
Society, 91, 272–279.
Lee, E., & Horvath, A. O. (2014). How a therapist responds to
cultural versus noncultural
dialogue in cross-cultural clinical practice. Journal of Social
Work Practice, 28, 193–217.
McNeill, T. (2006). Evidence-based practice in an age of
relativism: Toward a model for
practice. Social Work, 51, 147–156.
McNeill, T. (2010). Family as a social determinant of health:
Implications for governments
and institutions to promote the health and well-being of
families. Health Care Quarterly,
14, 60–67.
Mikkonen, J., & Raphael, D. (2010). Social determinants of
health: The Canadian facts.
Toronto, Canada: York University School of Health Policy and
Management.
National Association of Social Workers. (2001). NASW
standards for cultural competence in
social work practice. Washington, DC: NASW.
National Association of Social Workers. (2007). Indicators for
the achievement of the NASW

standards for cultural competence in social work practice.
Washington, DC: NASW.
National Association of Social Workers. (2008). NASW code of
ethics. Washington, DC: NASW.
Nybell, L. M., & Gray, S. (2004). Race, place, space: Meanings
of cultural competence in three
child welfare agencies. Social Work, 49, 16–26.
Parrott, L. (2009). Constructive marginality: Conflicts and
dilemmas in cultural competence
and anti-oppressive practice. Social Work Education, 28(6),
617–630.
Raphael, D. (2009). Restructuring society in the service of
mental health promotion: Are we
willing to address the social determinants of mental health?
International Journal of Mental
Health Promotion, 11, 18–31.
Ridley, C. R., & Lingle, D. W. (1996). Cultural empathy in
multicultural counseling: A multi-
dimensional process model. In P. B. Pedersen, J. G. Draguns,
W. J. Lonner, & J. E. Trimble
(Eds.), Counseling across cultures (4th ed., pp. 21–46).
Thousand Oaks, CA: Sage.
Sakamoto, I. (2007a). A critical examination of immigrant
acculturation: Toward an
anti-oppressive social work model with immigrant adults in a
pluralistic society. British
Journal of Social Work, 37, 515–535.
Sakamoto, I. (2007b). An anti-oppressive approach to cultural
competence. Canadian Social

Work Review, 24, 105–114.
Sakamoto, I., & Pitner, R. (2005). Use of critical consciousness
in anti-oppressive social work
practice: Disentangling power dynamics at personal and
structural levels. British Journal of
Saleebey, D. (2012). The strengths perspective in social work
practice (6th ed.). Boston, MA:
Pearson.
Simmons, C. S., Diaz, L., Jackson, V., & Takahashi, R. (2008).
NASW cultural competence
indicators: A new tool for the social work profession. Journal of
Ethnic and Cultural
Diversity in Social Work, 17, 4–20.
Sue, D. W., Ivey, A. E., & Pedersen, P. B. (1996). A theory of
multicultural counseling and
therapy. Pacific Grove, CA: Brooks.
Sue, D. W., & Sue, D. (2013). Counseling the culturally
diverse: Theory and practice (6th ed.).
Hoboken, NJ: Wiley.
Tsang, A. K. T., & Bogo, M. (1997). Engaging with clients
cross-culturally: Towards devel-
oping research-based practice. Journal of Multicultural Social
Work, 6, 73–91.
Tsang, A. K. T., Bogo, M., & George, U. (2003). Critical issues
in cross-cultural counseling
research: Case example of an ongoing project. Journal of
Multicultural Counseling and
Development, 31, 63–78.

Wakefield, J. C. (1995). When an irresistible epistemology
meets an immoveable ontology.
Social Work Research, 19, 9–17.
Wilkinson, R., & Pickett, K. (2009). The spirit level: Why more
equal societies almost always do
better. London, UK: Allen Lane.
Williams, C. C. (2006). The epistemology of cultural
competence. Families in Society, 87,
209–220.
SOCIAL WORK 299
AbstractCulture and diversity: framing the constructsCultural
competence in social work: significance and
controversiesCulturally competent practice models: strengths
and shortcomingsToward a critical model for working across
differences in social work practiceEvidence-based
knowledgeDiscrimination and inequality as social
injusticesHistory, colonialism, and neoliberal
ideologyPostmodernism, multiple identities, and
intersectionalitiesConceptual framework for practiceEcological
and strengths-based orientationsCritical approachesIntervention
strategiesIndividualize through clinical empathyDeindividualize
for anti-oppressive interventionsAgency and institutional
contextCritical self-awarenessImplications for social
workAcknowledgmentsReferences
Is Social Work Evidence-based? Does Saying So Make It So?
Ongoing Challenges in Integrating Research, Practice and
Policy
Eileen Gambrill

ABSTRACT
The integration of research and practice is of concern in all
helping profes-
sions. Has social work become an evidence-based profession as
some
claim? Characteristics of current-day social work are presented
that dispute
this view, related continuing concerns are suggested, and
promising devel-
opments (mostly outside social work) are described that should
contribute
to the provision of evidence-informed services to clients.
ARTICLE HISTORY
Accepted: December 2015
Social workers confront perhaps the most difficult tasks of any
helping professional. They work
at the nexus of individual distress often created by preventable
life inequities fostered by
economic, political, and social policies. The funding for their
work is shaped by these influences
and affects how they frame problems and the services they
offer, in addition to what is taught
and how it is taught in schools of social work. The multiple
functions of social welfare and social
work (helping clients, social control, and social reform)
guarantees that goal displacement and
conflicts will occur.
As in other helping professions, social work has had a long-term
interest in conducting and
drawing on research that contributes to helping clients (e.g.,
Hudson, 1982; Kirk & Reid, 2002;
Orcutt, 1990; Reid, 1994, 2001; Rothman & Thomas, 1994).

According to Reid (2001), there are
two uses of science in the helping professions: “One has been to
follow a scientific model in
conducting professional activities: science as method;” the
second has been “science as knowl-
edge” to be drawn on to inform practice” (p. 274). The
publications of early social work writers
reflect an interest in the scientific method and in research.
Charitable organizations in the
United States in the late 19th and early 20th centuries
emphasized scientific charity “described
as the ‘intelligent’ discriminating procurement of facts in the
investigation of needs” (Orcutt,
1990, p. 124). Social research was of great interest to the
women who created Hull House, a site
that included a Working People’s Social Science Club (e.g.,
Oakley, 2014). Social work scholars
drew on different disciplines and from a variety of theorists.
Karpf (1931) described knowledge
drawn by social workers from psychology and discussed
limitations of such knowledge. Jesse
Taft drew on the work of George Herbert Mead and Otto Rank
(Deegan, 1986). Lilian Ripple
(1957) conducted a study of factors associated with continuance
in social work, and Mary
Richmond (1917) drew on the scientific method as a guide to
gathering information. Virginia
Robinson (1921) noted that:
like any other profession which is founded on the scientific
method, social casework must move through three
stages: (1) observation and assembling of its facts, (2)
hypothetical interpretation of these facts, and (3) control
of the facts for new ends. (p. 101)
In the call for articles, the editors of the Journal of Social Work

Education state that the purpose of
this special issue “is to present the state of social work today as
grounded in empirical evidence” and
that “in the past 25 years we have seen a shift within social
work academia and practice across all
CONTACT Eileen Gambrill [email protected] School of Social
Welfare, University of California Berkeley, Berkeley, CA
94720, USA.
JOURNAL OF SOCIAL WORK EDUCATION
2016, VOL. 52, NO. S1, S110–S125
http://dx.doi.org/10.1080/10437797.2016.1174642
© 2016 Council on Social Work Education
methods that emphasizes research and evidence-based practice.”
In a publication from the American
Academy of Social Work and Social Welfare (2013) it was
claimed that “social work has matured . . .
to an evidence-based profession, relying on systematic data” (p.
1).
Has there been a shift? Is social work grounded in empirical
evidence?
There certainly has been an increase in use of the words
evidence based. An Internet search of the
terms social work and evidence-based practice (EBP) produces
many results. More social work
researchers are turning out more research, and the number of
journals containing social work
research has increased; for example, there is now a publication
titled Journal of Evidence-Based

Social Work. The common elements approach has also received
attention (Barth et al., 2012), and
websites and clearinghouses claim to list interventions in
relation to their evidentiary status. But
what is the quality of research conducted and reported? How
many practices offered to clients are
evidence informed (those most likely to result in hoped-for
outcomes)? A close examination of these
questions suggests that social work is not grounded in empirical
evidence. I suggest that we have
seen a shift mainly in language, not in substance. For the same
reasons that science is often
misrepresented, and critical thinking values, skills, and
knowledge have not been infused into social
work, so has the vision of EBP described in original sources
(e.g., Straus, Richardson, Glasziou, &
Haynes, 2011; Sackett, Richardson, Rosenberg, & Haynes,
1997) been forgone (e.g., to make
informed decisions attending to ignorance as well as
knowledge). All three are far too radical to
be embraced in the highly politicized and economically
contested areas of social work and social
welfare. We have often been the unwitting victims or
cosupporters of others’ agendas (e.g., biome-
dical psychiatry) that compromise opportunities to help clients
and that are encouraged by our lack
of understanding of the technological society in which we live.
Consider the following.
First, most social work interventions, including assessment
methods, have not been critically
tested in terms of their effects. We have no idea whether they
do more harm than good.
Second, information about what is offered to clients in social
work agencies is usually too vague to be

informative about the quality of services provided and outcomes
attained. Results found in searching
websites of some field agencies used at my school reveal only
vague information or reliance on surrogates
such as process measures to reflect quality of services (e.g.,
number of clients seen). Increased attention is
being given to data mining, especially administrative data
(Putnam-Hornstein et al., 2013). However, to be
valuable, the data mined must be available, reliable, and valid,
and it may not be (e.g., Gillingham, 2015).
Third, studies of practices and policies offered and their
outcomes often reveal that practices
promoted and used are often not those that are best. In Science
and Pseudoscience in Social Work,
Thyer and Pignotti (2015) describe an alarming variety of
questionable practices used by social
workers (see also Pignotti & Thyer, 2009). Their illustrations
indicate that life-affecting decisions
made regarding interventions are often neither theoretically nor
empirically well grounded; some
have been found to harm clients. Programs claimed to be
evidence based have been shown to be no
more effective than other methods (Gorman & Huber, 2009;
Littell, 2008).
Fourth, critical appraisal of published research (research on
research) reveals a very bleak picture.
Peer review is deeply flawed. Ioannidis (2005, 2008) argues that
most published research findings are
false or grossly exaggerated. Bias and selective reporting are
rife. Most research in psychology either
has not or cannot be replicated (Francis, 2012; Makel, Plucker,
& Hegarty, 2012). Campbell and
Cochrane Group’s (http://methods.cochrane.org/equity/)
systematic reviews typically reveal most

research reports to be flawed. Transforming the knowledge we
do have into use is a slow process.
Much of the published literature shares the goals and strategies
of advertisements for authors and
institutions rather than pursuit of knowledge (Gambrill, 2012).
The website Retraction Watch
(http://retractionwatch.com) is growing thanks to a $400,000
grant from the MacArthur
Foundation to catalog the thousands of retractions in articles in
peer-reviewed journals. Thus,
science is not necessarily self-correcting (Ioannidis, 2012). In
2005 the editors of leading medical
journals announced that reports of trials would not be published
unless they had been registered to
JOURNAL OF SOCIAL WORK EDUCATION S111
http://methods.cochrane.org/equity/
http://retractionwatch.com/
prevent authors from hiding negative reports (DeAngelis et al.,
2005; see also The Era of Clinical
Trial Registeries, 2005). Scientism (use of the methods or
language of science in contexts in which
they are not appropriate) abounds, including inappropriate use
of statistics (e.g., Ziliak &
McCloskey, 2008). The term evidence-based has become a
slogan used to sell products—articles
and books with hyped claims about what works. Avoidable
distortions of views are common
(Gambrill, 2010). Bogus claims about alleged discoveries in
neuroscience are common (see the
blog Neuroskeptic published by Discover magazine). Poor-
quality research misinforms rather than
informs the selection of practices and policies. Because they are

bamboozled by distorted views of
disliked perspectives and by inflated claims in the peer-
reviewed literature about what we know and
what is achieved, practitioners as well as administrators are in
the uncomfortable position of feeling
out of step, not current. Janko (1997) argues that false claims
contribute to indifference.
Political, social, and economic concerns in the helping
professions and related venues, including
research centers and governmental organizations, often
discourage telling the truth. Entrenched
ideas hamper acknowledgment of new ideas (e.g., Barber, 1961;
Campanario, 2009). Bauer (2004)
contends that science is dominated by research cartels and
knowledge monopolies. Social work
academics and researchers are influenced by their environments
(Bartley, 1990; Greenberg, 2007;
Veblen, 1918/1993). Social and economic pressures on
researchers encourage claim inflation, data
fudging, and other practices that misinform. A key requirement
is publication of original research
(e.g., Fanelli, 2010). Newly appointed professors must obtain
grants to help support universities
(Thyer, 2011), and granting agencies favor those who work
within popular frameworks. The
National Institute of Mental Health states that “Fundamental to
our mission is the proposition
that mental illnesses are brain disorders expressed as complex
behavioral and cognitive syndromes”
(as cited in Abramowitz, 2015). As Abramowitz notes, this
implies that cognitive and behavioral
processes are mere by-products (p. 35). And, what about the
role of environmental circumstances?
Fifth, social work has chosen to embrace the EBPs approach

rather than the process of EBP, which is
designed to help individual practitioners deal in an ethical,
informed manner with the uncertainties
and challenges of everyday practice (Straus et al., 2011),
drawing on tools such as the Campbell and
Cochrane databases of systematic reviews are designed to
decrease costs associated with drawing on
research findings. The EBPs approach is quite different from
the process of EBP and is more popular
today. Lists of interventions said to be evidence-based (EBPs)
are created and are used to guide
practitioners and to mandate what must be used. Problems with
such lists include inflated claims of
effectiveness in the peer-reviewed literature (see previous
paragraph) and the need to consider
individual differences in client characteristics and
circumstances that may render an evidence-based
intervention inappropriate. Promoters of EBPs will do more
harm than good if they are not well
informed about political, social, and economic influences that
shape the pool of literature available,
including peer-reviewed publications, and so are appropriately
skeptical about what they read.
Otherwise, they themselves become advertisers for dubious
claims, including those about problem
framing.
Sixth, social workers and social work educators have been slow
to draw on empirical literature
regarding the helping process, especially common factors and
the value of gaining ongoing feedback
regarding the degree of progress, both of which are associated
with positive outcomes (Lambert &
Shimokawa, 2011). Research suggests that common factors such
as empathy, warmth, and forming a
strong alliance contribute far more to positive outcomes than do

specific interventions (Wampold &
Imel, 2015). How many social work programs ensure that all
students acquire related minimal-level
competencies and use these in their interactions with clients?
Seventh, social work has continued its infatuation with
biomedical and institutional psychiatry and
certain areas of clinical psychology (e.g., Illouz, 2008; Lubove,
1965). Social workers are the main
providers of mental health services in the United States.
Misbehaviors and troubled or troubling feelings
and thoughts are given labels such as bipolar disorder,
attention-deficit/hyperactivity disorder, social
anxiety disorder, and hundreds of others, including gambling
disorder and female sexual interest/arousal
disorder, according to the Diagnostic and Statistical Manual of
Mental Disorders, now in its fifth edition
S112 E. GAMBRILL
(DSM-5; American Psychiatric Association, 1976). The client is
viewed as having an illness (mental) in
need of a diagnosis and treatment. Ivan Illich (1976) used the
term “the medicalization of life” (p. 39).
The boundaries on categories of alleged disorders such as social
anxiety continue to expand. One out of
four people is alleged to have a diagnosable mental disorder. To
most people, to question this view is
considered heretical and deluded, a reaction that shows the
spectacular success of equating (mis)behavior
and illness. Biomedical remedies for (mis)behaviors and
distress are promoted on the website of the
National Association of Social Workers). For example, on one
of its Web pages, Shryer (2012) states that

“stimulants are still the gold standard.” For further information,
he recommends CHADD.org, an
organization funded primarily by pharmaceutical companies.
Critiques of the disease-centered model
of psychotropic drug action are ignored (e.g., Moncrieff, 2008b,
2013a, 2013b), as are penetrating
critiques of the concept of mental illness (e.g., Kirk, Gomory, &
Cohen, 2013; Szasz, 1987) and lack of
reliability and validity of the DSM-5 (American Psychiatric
Association, 2015) (e.g., Kirk et al., 2013).
Sociologists emphasize the social construction of personal and
social problems, for example,
framing political concerns such as equality of rights or freedom
from unwanted control as personal
ones the state has power over (see Foucault, 1973; Illich, 1976;
Mills, 1959). There are great stakes in
how problems are framed, and people with vested interests
devote considerable time, money, and
effort to influence what others believe (Loeske, 1999).
Psychological and biomedical views ignore
contextual factors and related research showing the influence of
environmental factors on health,
psychological distress, and behavior (e.g., Adler & Stewart,
2010). This is remarkable in a profession
concerned with oppression and discrimination and the need for
social reform. Ignoring social,
political, and economic factors that affect clients’ lives results
in incomplete analyses of client
concerns (oversimplifications) and lost opportunities to help
clients.
Eighth, empirical research and the related theory regarding the
science of behavior (e.g, Madden,
2013; Staats, 2012) is typically ignored in social work
education and in many areas of practice.

Discussions of strengths-based social work typically ignore
behavioral research and related theory
describing a constructional approach to helping. Related theory
is often distorted (Thyer, 2005).
Problems differ in their prospects for resolution, which are
influenced by the accuracy of under-
standing; client concerns may be framed in a way that facilitates
or hinders the discovery of options.
A biomedical approach focuses on identifying disorders of
clients, or what is wrong with them. A
constructional approach focuses on identifying client strengths
and developing alternative behavioral
repertoires in pursuit of hoped-for outcomes (Layng, 2009;
Staats, 2012). This science of behavior
offers emperically informed constructive ways to rearrange
environments including helping clients
to create alternative repertoires that compete with disliked
behaviors.
Ninth, as illustrated in earlier sections, critical thinking, values,
skills, and knowledge are not in
abundant evidence in much of the discourse in social work. This
can be seen in avoidable distortions
of ideas, false claims about the evidentiary status of policies
and programs, use of vague language,
and ignoring compelling critiques of views promoted (see prior
discussion). The terms science and
scientific are often used to merely increase credibility of
claims. Such use is a form of propaganda
(encouraging beliefs and actions with the least thought possible;
Ellul, 1965). Thinking critically
about claims is not valued by many groups and individuals; on
the contrary, they may try to hide the
effects of practices and policies and appeal to pseudoscience.
Interest in status and money looms
larger than helping clients and telling the truth.

Related continuing concerns
A variety of failures of integration continue. Focusing on the
thoughts and brains of individuals as
the source of problems continues in much of social work
including social work education, deflecting
attention from the dehumanizing effects of the technological
society in which we live (Ellul, 1964,
1965; Stivers, 2004, 2008). Social work has drawn heavily on
psychiatry and cognitive psychology,
ignoring vital contributions of sociology, evolutionary
psychology, and behavioral psychology. Lack
of awareness regarding the influence of the public relations
industry, the media, and the biomedical
industrial complex in promoting misleading claims is a barrier
to recognizing social, political, and
economic causes of personal and social problems including poor
health, homelessness, and poverty.
Social work is for the most part a woman’s profession, yet
academics have forwarded a psychiatric
view that pathologizes women (e.g., Ussher, 2013).
Naïveté regarding the technological society in which we live
Those who work in the area of critical social work highlight the
effects of structural factors in
creating and maintaining discrimination and social exclusion
but overlook Ellul’s (1964, 1965)
penetrating analysis of the mass society in which we live that is
dominated by technique and its

dehumanizing effects. “Technique refers to any standardized
means for attaining a predetermined
result. Thus, it converts spontaneous and unreflective behavior
into behavior that is deliberate and
rationalized. ” (Ellul, 1965, p. vi). Ellul (1965) argues that we
live in a technological society
dominated by the mass media, which creates alienation and
fragmentation resulting in loneliness,
anxiety, and a desperate search for meaning. Technology
includes material (manufactured products)
and nonmaterial creations such as bureaucracies and
administrative systems. The mass media,
advertising, public relations, propaganda, and bureaucracies are
all techniques. Case records and
surveillance systems are technologies. Self-help books and
psychotherapies are techniques. We spend
our time looking at, listening to, and talking to machines. Many
social work scholars note the
increase in required administrative tasks (the tick-box
mentality) and its negative effects including
decreased time between clients and social workers (e.g., Munro,
2011; Rogowski, 2011, 2013).
Technologies become increasingly interrelated so that a change
in one (a data management system)
may be countered or amplified in another. Technology presses
for ever greater efficiency, standar-
dization, systematization, and the elimination of variability,
which requires inattention to individual
differences. It squeezes out the qualitative. Ellul (1964)
suggests that technology has become the new
sacred.
The medicalization of deviance is an example of the
universality of technology (Stivers, 2008).
Disliked behaviors are viewed as illnesses fixed by technologies
of medication or therapy, guided

by standardized codes and labels. Health and happiness are
equated with adjustment. Cognitive
therapy reduces us to our thoughts. Biological views reduce us
to brain chemistry. Both ignore
cultural contexts and individual subjectivities, and complex
interactions among them. Stivers
(2008) argues that “the medicalization of deviance denies both
the freedom and the responsibility
of the actor” (p. 46). Szasz (1961, 1987) has argued this for
more than half a century.
This technological society is foreign to human needs for
community and social relations. It
creates negative psychological and social consequences
including loneliness and anxiety and
fragmentation and splits such as that between belief and action.
There is an illusion of freedom
(Stivers, 2008). Moral problems are converted into social
problems (Stivers, 2001). Because power
is located in abstract systems such as bureaucracies, it is
difficult or impossible to pinpoint and
change. Propaganda is the means used to prevent increasing
mechanization and technological
organization from being felt as too oppressive. It is “called
upon to solve problems created by
technology, to play on maladjustments, and to integrate the
individual into a technological world”
(Ellul, 1965, p. xvii). It is interested “in shaping action and
behavior with little thought” (Ellul,
1965, p. 278). A major function is to squelch criticism and
censor dissenting points of view.
Related examples illustrate the deep ethical and epistemic
concerns with propaganda
(Cunningham, 2002). Ellul (1965) argues that, “adjustment has
become one of the keywords of
all psychological influence” (p. 107) such as adapting to

dehumanizing working conditions (see, for
example, the discussion of the mental hygiene movement in
Lubove, 1965). Stivers (2001) argues
that much of the advice in therapy and self-help books is
“conformist” (p. 60). The products of
social science are drawn on to maximize the effectiveness of
propaganda. Edward Bernays, the
founder of the field of public relations, drew on psychoanalytic
theory: “The individual can no
S114 E. GAMBRILL
longer judge for himself because he inescapably relates his
thoughts to the entire complex of values
and prejudices established by propaganda” (Ellul, 1965, p. 170).
Ellul (1965) states that “intellectuals are most easily reached by
propaganda” (p. 113) because they
read so much material in secondary sources. As illustrated in
prior sections, propaganda is not
confined to fringe healers; it has a robust presence in the peer-
reviewed literature including inflated
claims of knowledge and effectiveness. Propaganda methods
include oversimplifications, creation of
fear, begging the question (simply asserting what should be
argued), appeal to self-interest, and
censorship of alternative views and contradictory evidence
(Gambrill, 2012). A review of advertising
on marketing brochures distributed by drug companies to
physicians in Germany revealed that 94%
of the content in these had no basis in scientific evidence
(Tuffs, 2004).
Continuing misrepresentations and misunderstandings of

science
A concern for helping and not harming clients obliges us to
critically evaluate assumptions about what
is true and what is false. Relying on scientific criteria offers a
way to do so. The essence of science is
bold guessing and rigorous testing. This view of science as we
know it today is one in which the
theory-laden nature of observation is assumed (i.e., our
assumptions influence what we observe), and
rational criticism is viewed as the essence of science (Miller,
1994; Phillips, 1992; Popper, 1963).
Concepts are assumed to have meaning and value even though
they are unobservable. This view of
science emphasizes the elimination of errors by means of
criticism (Popper, 1994, p. 159).
Science rejects a reliance on authority (e.g., pronouncements by
officials or professors) as a route
to knowledge. “Science is the belief in the ignorance of experts”
(Feynman, 1969). Far from
reinforcing myths about reality, science is likely to question
them. All sorts of questions people
may not want raised may be raised, such as, Does this
residential center really help residents?
Scientific statements can be tested (they can be refuted). If an
agency for the homeless claims that
homes are found for applicants within 10 days, data could be
gathered to see whether this claim is
true. Scientists are often wrong and find out they are wrong by
testing their predictions. Although
the purpose of science is to seek true answers to problems
(statements that correspond to facts), this
does not mean that we can have certain knowledge. A critical
attitude, which Karl Popper (1963)
defines as a willingness and commitment to open up favored

views to severe scrutiny, is basic to
science, distinguishing it from pseudoscience. Scientists are
skeptics. They question what others view
as fact or common sense. They ask for arguments and evidence.
Surveys show that most people do not understand science
(National Science Foundation, 2006).
We are surrounded by pseudoscience and propaganda, making it
a continuous challenge to resist
their allure (e.g., Gambrill, 2012; Lilienfeld, Lynn, & Lohr,
2015; Thyer & Pignotti, 2015). The term
pseudoscience refers to material that makes sciencelike claims
but provides no evidence for them
(Bunge, 1984). Science is often misrepresented in the social
work literature. Some academics confuse
logical positivism with science as we know it today (Shadish,
1995). The former approach was
discarded decades ago because of the induction problem, the
theory-laden nature of observation, and
the utility of unobservable constructs (e.g., Phillips, 1990;
Popper, 1963, 1994). Science is often
misrepresented as a collection of facts or as referring only to
controlled experimental studies. Many
people confuse science with pseudoscience and scientism (false
claims of being scientific (Phillips,
1987). Relativists argue that all methods are equally valid in
testing claims. It is assumed that
knowledge and morality are inherently bounded by or rooted in
culture. Gelner (1992) argues that
this view undervalues coercive and economic constraints in
society and overvalues conceptual ones
(see also Munz, 1992).
Forgoing the essence of critical thinking: Criticism
Thinking critically has costs and benefits that are shared by the

process of evidence-informed
practice and scientific exploration. Costs include forgoing the
comfortable feeling of certainty and
the time and effort required to accurately understand alternative
views and to seek and critically
appraise research findings. It may result in loss of shared social
bonds (Munz, 1985). Phillips (1992)
argues that raising questions about truth has the taboo quality
today that talking about sex had in
Victorian times. To those who uncritically embrace the view
that they are helping others, asking that
verbal statements of compassion and caring be accompanied by
evidence of helping may seem
disloyal or absurd. According to Ellul (1965), “If we practice a
profession, we cannot limit ourselves
to its financial rewards, we must also invest it with idealistic or
moral justification. It becomes our
calling, and we will not tolerate its being questioned” (p. 157).
It takes courage to challenge accepted beliefs, especially when
held by authorities who do not
value a culture of thoughtfulness in which well-argued
alternative views are welcome and
arguments critically evaluated. To the autocratic and powerful,
raising questions threatens
their power to simply pronounce what is and is not without
taking responsibility for presenting
well-reasoned arguments and involving others in decisions.
Socrates was sentenced to death
because he questioned other people’s beliefs (see Plato’s
Apology, trans. Tredennick & Tarrant,

1954/1993; Janko, 1997). Evolutionary history highlights the
powerful role of status (Gilbert,
1989). The student who questions a professor, supervisor,
administrator, or physician may be
viewed as a threat rather than as a source of knowledge that
may help clients attain goals they
value.
Promising developments
In the reality that the future holds a promise of new paths, we
could say that we are always at a
critical juncture. I suggest that we are at a critical juncture but,
as argued earlier, not because
social work is “grounded in empirical evidence” and
“emphasizes research and evidence-based
practice” as stated by the editors of this journal in their call for
articles. Quite the opposite; in
most cases we have the words but not the substance. I suggest
the following developments, most
of which are outside social work, that should contribute to more
accurate accounts of current-
day social work practice, policy, and research as well as the
provision of evidence-informed
services to clients.
Increased exposure of false claims and flaws in research and
calls to decrease related waste
Exposure of bogus claims in the peer-reviewed literature has
increased, as discussed earlier in
this article. This started in the medical and biomedical area
(Ioannidis, 2005, 2014). Ioannidis
(2014) estimates that billions of dollars have been wasted on
research that cannot answer
questions pursued. This waste has reached such enormous

proportions that efforts are now
under way to decrease it, including the creation of a new center
at Stanford, The Meta-research
Innovation Center (METRICS) (see also Chalmers et al., 2014;
Ioannidis et al., 2014).
Recognition that all was not well in the peer-reviewed literature
was the impetus for creation
of the International Congress on Peer Review and Biomedical
Research held every 4 years since
1986. The Journal of Negative Results in Biomedicine publishes
negative and unexplained or
controversial research, often rejected by mainstream journals.
Some journals have introduced
negative results sections (e.g., Dirnagl & Lauritzen, 2010), and
open peer review is becoming
more common (e.g., Shanahan & Olsen, 2014). What will we
find when we carefully examine the
quality of social work research? Exposures of bogus claims also
appear in our daily newspapers
(e.g., Teicholz, 2015) and on websites such as Retraction
Watch. Reid (2001) suggested that “A
strong case can be made that a critical mass of tested
intervention knowledge has been
established” (p. 278). Is this true, even 15 years later? Critical
appraisal of research suggests
that it is not. Conducting research that cannot answer questions
raised is a great waste of money,
time, and effort. Related false claims mislead practitioners and
clients alike.
S116 E. GAMBRILL
Increasing user-friendly tools for acquiring critical appraisal
skills

Increasingly user-friendly websites are available for honing
critical appraisal skills, such as http://
www.testingtreatments.org. Content is available in multiple
languages. This site includes discussion
of important topics such as the vital difference between relative
and absolute risk and correlation and
causation. Campbell and Cochrane databases provide systematic
reviews. User-friendly websites such
as www.fallacyfiles.com can be drawn on to enhance critical
thinking skills.
Increasing criticism of the biomedical industrial complex
Biomedical industrial complex refers to the increasingly
globalized interconnections among phar-
maceutical, biotechnological, medical, public relations, research
contracting, and educational indus-
tries with funding agencies, private and governmental, and
various lobbying groups (Gomory,
Wong, Cohen, & LaCasse, 2011; Clarke, Mamo, Fosket,
Fishman, & Shim, 2010; Orr, 2010) Its
growth and ever more intertwined relationships and use of
technologies (e.g., for diagnosis, billing,
selection of interventions, surveillance) illustrate the
technological society in which we live, ever
more standardized, interconnected, and decontextualized.
Conflicts of interests abound, which is
described later. The past few years have seen increasing
critiques of the medicalization of problems
in living (e.g., Kirk et al., 2013), including in the field of
psychiatry itself (e.g., Frances, 2010). Social
work scholars have been at the forefront of documenting
reliability and validity problems with the
ever lengthening list of problems in living viewed as “mental
illnesses” in the DSM (American

Psychiatric Association, 2015; Kirk, Gomory, & Cohen, 2013).
Moncrieff (2008a) argues that
biological psychiatry forwards neoliberal political agendas.
Claims that changes in serotonin are
responsible for depression have been debunked by social work
scholars (LaCasse & Leo, 2005).
Drug companies benefit from the creation of new diseases, such
as panic disorder and pre-
menstrual dysphoric disorder, by increasing markets for their
medications (Conrad, 2007). The
definition of social anxiety and depression as brain diseases
requiring medication benefits the
pharmaceutical industry. Cohn & Wolfe, a public relations
company hired by GlaxoSmithKline to
lay the groundwork for the introduction of Paxil, created the
term social anxiety disorder and
popularized this diagnosis (Moynihan & Cassels, 2005). The
promotion of the belief that deviant
behaviors are caused by an illness (a brain disease) has spawned
scores of industries and thousands
of agencies, hundreds of research centers, and thousands of
advocacy groups that advance this view.
Residential psychiatric facilities for youths and nursing homes
are multimillion-dollar businesses
(see the section titled “Increased Attention to Fraud and
Corruption”).
Increasing critique of clinical psychology
Illouz (2008) also emphasizes splits created by our
technological society and its alienating effects in
her probing critique of the grand narrative of clinical
psychology, which focuses on the thoughts and
emotions of individuals, ignoring their ever changing nature and
related contextual factors. She

notes that this attention to thoughts and emotions was of great
interest to corporations to “manage”
the workforce. The “therapeutic culture” and related discourses
offers endless possibilities for
“coherently narrativising the life story through its ‘diseases’”
(p. 196). Much of behavior therapy
changed over the years from a focus on the influence of learning
experiences to a focus on thoughts;
for example, the Association for Behavioral and Cognitive
Therapy promotes the mental illness view
of behavior (e.g., Abramovitz, 2015).
Increased client involvement
An Internet search of “social workers and complaints” reveals
many websites containing related
material, especially concerning child welfare services (see
“What Happens When Child Protective
http://www.testingtreatments.org
http://www.testingtreatments.org
http://www.fallacyfiles.com
Services Is Busy Hounding Free Range Parents,”
www.freerangekids.com). AbleChild.org works against
what parents view as harmful psychiatric labeling of their
children and use of medication.
MindFreedom International (http://www.mindfreedom.org) was
created in 1990 to work against
psychiatric practices of restraints, involuntary commitment,
electroshock, and forced medication.
Intervoice.org (the International Hearing Voices Network)
offers an alternative to stigmatization for

those who hear voices. Increasing attention is being given to
involvement of clients in research and as
informed participants in the helping process (e.g., Coulter &
Ellins, 2006; Edwards & Elwyn, 2009;
Kaltoft, Nielsen, Salkeld, & Dowie, 2014). For example, the
Cochrane Collaboration (http://www.
cochrane.org) maintains a consumer network.
Increased attention to harming in the name of helping
Even in the best of circumstances, given the uncertainty
surrounding problems and the lack of
resources for altering circumstances, failure to help clients and
perhaps even harm will occur. And
bad outcomes do not necessarily reflect poor decisions. But
much harm is preventable such as the
excessive use of psychotropic medication for children (U.S.
Government Accountability Office, 2012)
and the elderly (Tija et al., 2014; see also Gambrill, 2012;
Lilienfeld, 2015) Social workers should take
a far more active role in exposing harming in the name of
helping (see the discussion in the section
“Increased Attention to Fraud and Corruption.”)
Increased attention to errors
Avoidable medical errors are the third leading cause of death in
the United States (James, 2013).
Little attention has been devoted to errors in social work (for an
exception see Munro, 1996). Errors
and mistakes are inevitable and provide valuable learning
opportunities. This is recognized in many
areas, including medicine, aviation, and nuclear power where
mistakes are actively searched for.
Errors are usually due to systemic factors, including poor
training (as described in the classic book

by Reason, 2001). Feedback is an essential part of learning;
only by recognizing our mistakes and
errors can we make better guesses about how to avoid them in
the future. Unavoidable errors occur
despite researchers’ taking advantage of available knowledge
and critical thinking skills and in spite
of making and acting on well-informed judgments. Avoidable
errors are those that could have been
avoided, for example, by being better informed regarding
practice-related research findings, by
thinking more critically about assumptions and by carefully
tracking progress. A recognition of
and active search for errors keeps the inevitable uncertainty
involved in trying to help clients clearly
in view.
Increased attention to the role of cognitive biases in decision
making
Cognitive biases, such as the fundamental attribution error (the
tendency to focus on a person’s
characteristics and to neglect environmental circumstances), are
a source of error in decision
making. Here too we are out of step with developments in some
other helping professions, especially
medicine, in which considerable attention is being given to
cognitive biases (e.g., Croskerry, 2003; for
an exception, see Gambrill & Gibbs, 2009, 2012). Confirmation
biases influence judgment in all
phases of work with clients: defining problems, deciding on
causes, and selecting service plans. We
tend to seek and overweight evidence that supports our beliefs
and ignore and underweight contrary
evidence (Nickerson, 1998). Assignment of a label to a client
may result in a selective search for data
that confirm the label, while contradictory data may be ignored.

Anchoring effects may result in
inaccurate assessment and selection of ineffective or harmful
plans. We use different standards to
criticize opposing evidence than to evaluate supporting
evidence. We tend to recall our successes and
overlook our failures. This is one reason intuition may lead us
astray.
S118 E. GAMBRILL
http://www.freerangekids.com
http://www.mindfreedom.org
http://www.cochrane.org
http://www.cochrane.org
Increased attention to fraud and corruption
Fraud is the intentional false representation of a matter of fact
to obtain an unfair gain (e.g., status,
money). For example, effects of prescribed medication may be
misrepresented, risk factors may be
treated as diseases, and absolute risk may be hidden. A variety
of propaganda ploys, such as the
omission of relevant information is employed in fraudulent acts.
Fraud is common in the conduct of
research, as discussed earlier (e.g., Gupta, 2013; Resnik &
Master, 2013; Tavare, 2012). Increased
attention has been given to fraud and corruption in biomedical
psychiatry as well as in health care
(for example, undeclared conflicts of interest; Angell, 2011;
Gøtzsche, 2013; Mackey & Liang, 2012).
For example, most members of many DSM Task Forces have
financial ties to pharmaceutical
companies (Cosgrove, Bursztajn, Krimsky, Anaya, & Walker,
2009). Conflicts of interest between

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