Background and Specific Aims

Mutual interests and shared aims of the Institute for the Advancement of Social Work Research (IASWR) and the Office of Behavioral and Social Sciences Research (OBSSR) at the National Institutes of Health (NIH) with respect to enhancing scientific research on health-related psychosocial intervention led to the decision to co-sponsor the 1996 Symposium on Psychosocial Intervention Research: Social Work's Contribution. These shared goals are based in the mandates of both IASWR and OBSSR.

In 1993, Congress created OBSSR within NIH to address critical issues related to the funding of scientific research on behavioral and social factors relative to their contributions to health and illness and compared with funding for the biomedical sciences. Among the mandates of OBSSR is the development and ongoing refinement of a standard definition of behavioral and social sciences research to assess and monitor NIH's funding in the behavioral and social sciences, the facilitation of behavioral and social science research initiatives across NIH institutes, and the identification and promotion of scientific agendas that merit NIH support. Consistent with these aims and through numerous strategic efforts, OBSSR seeks input from a broad range of health disciplines and professions about the state and types of behavioral and social science funded within and outside of NIH.

IASWR was established in 1993 and is jointly sponsored by the National Association of Social Workers (NASW), the Council on Social Work Education (CSWE), the National Association of Deans and Directors of Schools of Social Work (NADD), the Group for the Advancement of Doctoral Education (GADE) and the Association of Bachelor Program Directors (BPD). As the scientific and research arm of the profession, IASWR has unique links to both the practice and educational communities of the social work profession. In establishing IASWR, the social work profession acted in response to the urgent recommendations of the Task Force on Social Work Research sponsored by the National Institute of Mental Health (NIMH).

The Task Force Report (1991) dramatically portrayed the nation's critical need for research on many of the nation's most serious social and human problems, such as serious mental and emotional problems of children and adolescents who have suffered child abuse and neglect or witnessed family violence and the need to prevent and treat substance abuse among all ages. Underscoring the primary role of social workers in providing services to prevent or treat many of these social problems, the Task Force Report also documented the striking lack of research infrastructure within the social work profession to contribute to the much needed research on health and human services for these problems. Thus this landmark report revealed the strategic position of the social work profession to conduct critical scientific research, but also concluded that neither the profession nor the relevant federal research agencies had invested in building research capacity within social work. At the same time, the report noted that other health-related professions had developed their research capacity with the aid of collaborative investment from federal research funding agencies.

IASWR represents a significant component in the profession's ongoing efforts to build this capacity and the primary mission of IASWR is to promote and strengthen the social work profession's contributions to scientific research. Included in its mandate, are efforts to engage relevant federal agencies in collaborating with the social work profession by investing in research infrastructure-building.

In this particular collaborative effort, IASWR and OBSSR sought to achieve shared goals through a national conference on social work's contribution to health-related psychosocial intervention research. To aid in ensuring that the conference would address intervention research priorities across NIH institutes, additional support and active participation was obtained from the NIMH, the National Institute of Drug Abuse (NIDA), the National Heart, Lung and Blood Institute (NHLBI), the National Institute on Aging (NIA), and the National Cancer Institute (NCI).

Specific aims of the Symposium on Psychosocial Intervention Research: Social Work's Contribution included:

o to bring together social work researchers and NIH program staff to facilitate communication and heighten awareness of common research interests and scientific priorities and to identify near and long-term psychosocial intervention research priorities.

o to promote and facilitate health-related psychosocial intervention research within social work.

o to identify areas of research that have been underrepresented at NIH, but that merit further attention across NIH institutes.

o to examine barriers to and opportunities for conducting research in real-world health-related practice systems and among highly vulnerable populations so often served by social workers.

o to identify interventions that are multi-dimensional, that is address both person and environmental elements of targeted problems.

o to examine the applicability of interventions found to be effective for a specific population across relevant NIH institutes.

o to identify next steps in areas of research that are well-developed, but have yet to be tested among specific populations or in real-world service systems.

Significance of Psychosocial Intervention Research for NIH

Focusing attention on health-related psychosocial intervention research is directly responsive to research priorities of OBSSR and the NIH. An extensive body of research (much of which has been NIH funded) documents profound effects of behavioral and social factors on the etiology, course, and management of illness. Indeed, such factors contribute to a least 50% of all annual deaths in the United States. Moreover, significant advances have been made in our understanding of the etiology, detection, diagnosis and epidemiology of mental disorders (Health Care Reform for Americans with Severe Mental Illnesses: Report of the National Advisory Mental Health Council, 1993). Consistent with the mounting evidence on the relationships between psychosocial factors and illness and disease, a smaller, but growing body of psychosocial intervention research documents the efficacy of health-related community-based, group, family, and individually-focused psychosocial interventions. Controlled clinical treatment trials have led to dramatic improvements in the pharmacological and psychosocial (often in combination) treatment of severe mental disorder. Thus, there is now a compelling scientific basis for expanding all types of behavioral and social science research, including psychosocial preventive, treatment, and rehabilitative intervention research.

Significance of Enhancing Social Work Intervention Research to Improve Health Outcomes

Increasingly, health and human service policy and programs will be informed by rigorous scientific research. The public and policymakers will increasingly demand both quality and cost data concerning the provision of health and human services and monitoring mechanisms will be in place to help ensure that the programs and treatments known to be effective are, indeed, provided.

Social workers provide critical services throughout the nation's health and human service system. They provide patient and family-focused psychotherapy, counseling, case management, education and social services throughout the public and private mental health, substance abuse, social service, and general health care systems. (The latter include public health, primary care, emergency rooms, out-patient clinics, general and specialty hospitals, rehabilitation facilities, home health agencies, hospices, and nursing homes.)

Social workers frequently provide services for persons and their families with multiple individual and social risk factors. These individuals are encountered by social workers throughout the health and mental health and human service systems. They include: 1) persons with demonstrated inability for self-care, cognitive impairment, persistent unemployment, inadequate economic and social resources, illiteracy and low education, inadequate family and social support systems; 2) children from severely troubled and unstable families; 3) victims of violence and abuse; 4) isolated elders in both urban and rural communities; 5) persons with co-morbid conditions; and 6) persons whose access to and utilization of mental health care is problematic. The challenges presented by these patient populations underscore a particular need for treatment/intervention studies that integrate individually-focused treatment with environmentally-focused interventions and that involve multi-dimensional and multi-disciplinary interventions.

Data from the Statistical Branch of the NIMH as well as the following organizational profile begins to illustrate the breadth of social work mental health and health care practice:

o NIMH data indicate that social workers comprise 8.7 percent of the full-time staff in all mental health organizations (Mental Health, United States, 1992). This compares with 3.4 percent for psychiatrists and 4.4 for psychologists.

o With respect to child and adolescent mental health, NIMH data indicate that social workers represent 10.7 percent of the full-time staffs of residential treatment centers for emotionally disturbed children (Mental Health, United States, 1992) versus 3.2 percent psychologists and 1.1 percent psychiatrists. Social workers are primary mental health service providers in managed care, the child welfare system and are also major mental health service providers in schools, public health, juvenile justice, substance abuse and the formal mental health systems.

o There are approximately 4200 social workers in the Veterans Administration health care system.

o The National Association of Social Workers (NASW) has 155,000 members. In a recent study of its membership, 32% listed mental health as their primary practice area and another 27.7% placed it second. Another 20% listed health care as their primary practice area.

o NASW recent estimates indicate that social workers are the largest group of practicing psychotherapists in the United States. There are approximately 80,000 clinical social workers in practice, compared with approximately 40,000 psychiatrists and 45,000 psychologists. The NASW also reports data indicating that in rural counties throughout the U.S., social workers are often the only resident mental health care provider. Roughly, 11,500 master's degreed social workers graduate each year compared with 1,300 psychiatric residents and 1,300 Ph.D. clinical psychologists.

o The National Federation of Societies for Clinical Social Work has 31 state societies and represents 9,500 licensed clinical social workers. The AHA Society of Social Work Administrators in Health Care has approximately 2500 members. The Association of Oncology Social Workers has approximately 1,000 members. Other organizations such as the Social Work Section of the American Public Health Association, National Association of Perinatal Social Workers, and Council of Nephrology Social Workers (NKF) include approximately 1500 members.

The NIMH Task Force Report (1991) documented the lack of investment in social work research by the profession and by federal agencies and the result of underinvestment. As the scope of its practice, number of practitioners, and problems of serious social concern with which it dealt continued to grow, the need for knowledge concerning "what works, for whom, under what circumstances" far outstripped the capacity of the relatively few career social work researchers. This gap between the capacity for knowledge-building to support practice and the needs of practice is particularly significant in the health and mental health area where social workers are primary service providers. Increasing social work-initiated research on the effectiveness of services has the potential to directly benefit human service delivery systems and the persons receiving social work services.

The NIMH Task Force Report (1991) specifically recommends increased support for social work research development and training from federal research funding agencies that are charged with the mission of developing the knowledge-base for health and human services. Despite the profession's major health practice profile, NIH-funded research on social work treatment and services in health and mental health has been relatively sparse. This lack of support occurs despite the fact that numerous social work research priorities logically fall within the scientific priorities of many NIH institutes. Underinvestment in research on social work health-related practice is certainly, in large part, attributable to competition for scarce research dollars. However, the lack of investment in these areas also carries significant cost to the nation insofar as it is correlated with major gaps in knowledge about social work treatment and service delivery outcomes as well as data to inform current public policy deliberations on cost, service program models, and quality of social work services.

In recent years, the NIMH has acted on the Task Force Report and has provided significant support to build research infrastructure within social work and the mutually beneficial effects of initiatives in this area are becoming evident. The 1996 Symposium was one preliminary effort to specifically spur intervention research within social work that is consistent with the scientific priorities of not only NIMH, but other NIH institutes, and to facilitate wider NIH support to advance research on social work interventions.

Symposium Planning, Design, and Participation

To ensure that an adequate design for the symposium was developed and to carry out specific tasks prior to and during the symposium, IASWR created and convened a Symposium Planning Committee. The Planning Committee was composed of representatives from the social work research community and NIH staff from each of the sponsoring NIH institutes (see attached Symposium Program).

The two-day symposium was designed to include presentations on three levels of research: interventions that have been studied under NIH auspices; interventions that have been studied outside of NIH; and interventions that are promising and merit further developmental support. Thus the format of the symposium included: 1) invitational presentations by a leading social work researcher on a body of research in a specific substantive area followed by discussion by social work researchers and NIH staff; 2) solicited peer-reviewed reports of specific studies followed by discussion by social work researchers and NIH staff; and 3) a scientific poster session showcasing preliminary studies and research in progress. In addition, all participants were assigned to a strategic working group to develop recommendations for further steps to be taken by social work and NIH to advance intervention research within social work and to help ensure that research that naturally emerges from social work practice is included among NIH priorities. A panel of NIH staff presented relevant research priorities within their respective institutes and information on technical assistance and funding mechanisms within their programs. At the conclusion of the meeting, a panel of leaders representing NASW, CSWE, NADD, GADE, the newly organized Society for Social Work and Research, and IASWR addressed recommended actions that grew out of the Symposium.

The Planning Committee identified leading social work researchers in specific substantive and invited them to prepare papers summarizing the state of research in their area of expertise. Information about the symposium and a call for papers and poster presentations was widely disseminated to social work audiences. All papers and poster presentations were reviewed by two members of the Planning Committee using previously determined criteria. Nine invitational presentations were made, nine specific studies were reported on, and thirty-two posters were presented. (See attached Program for details). The Symposium keynote was made by Dr. Norman Anderson, Director of OBSSR. Over one-hundred twenty social workers attended the Symposium. Notably, over forty NIH staff participated in the conference.

Psychosocial Intervention Research Highlighted During the Symposium

During two days of presentations and discussion, Symposium participants highlighted some of the most challenging areas for intervention research. These included substance abuse, schizophrenia, behavioral problems of urban children, men who batter, chronic pain, tuberculosis, child abuse and neglect, low income pregnant women, rural elders with mental illness, AIDS, Alzheimers disease, heart transplant patients, children with serious emotional disturbances, elderly at risk of suicide, home care for the elderly and caregivers. Interventions presented included a broad range of individual, family and group approaches, such as family preservation, multi-systemic family treatment, task-centered treatment, assertive community treatment and family treatment for persons with persistent and serious mental illness, telephone counseling, supportive groups, school-based programs, and use of peer workers.

Summary

The Symposium provided strong evidence of the importance of behavioral and social science research as it relates to the health of individuals and families. Social work should take heart in the scientific evidence that supports many of the profession's long-held beliefs about the importance of social and psychological factors and in the fact that the NIH includes among its scientific priorities many of the areas of major concern to practicing social workers. The Symposium also significantly expanded a mutually beneficial dialogue between the social work profession and the NIH.

The Symposium demonstrated convincingly that the issue, is no longer whether rigorous psychosocial intervention studies will be conducted, nor whether the results of that research will be used to influence health care policies and practices. The question is will social work significantly increase its contributions to this important area of research and will NIH assist social work in building its research infrastructure? And in so doing, contribute to the care and treatment of many of the most serious health problems, particularly as they are experienced among the most vulnerable populations. And bring into greater focus interventions that include environmental dimensions of these problems, a focus that is central to addressing serious health and related social problems. The current state of the science, including technological advances in behavioral and social science methodologies, provides opportunities to advance knowledge even faster as we enter the 21st century. The Symposium demonstrated that social work has both opportunity and obligation to make significant contributions to the development of empirically-based knowledge in health-related prevention, treatment, and rehabilitation. It further demonstrated that the scientific agenda of NIH would be strengthened by making targeted efforts to support social work research.

Empirical data will be a formidable tool in social work's efforts to influence the shape of health-related service delivery in ways that are consistent with its most basic values and goals. The dedicated and enthusiastic participants of the Symposium provided tangible evidence that history will record this time as one during which social work accepted the challenge to increase its application of and contribution to its scientific knowledge base to improve the health and quality of life of the nation, including its most vulnerable people, and that NIH, as the nation's premier scientific agency for health-related science can be a valuable partner in this effort.

Recommendations Developed from the Symposium

Recommendations developed from the Symposium include: 1) research priorities of NIH institutes that are of equal importance to the social work profession; 2) examples of priority areas of intervention research in which social might make significant contributions; 3) actions to be undertaken by schools of social work to develop a critical field of intervention and health and human service researchers; 4) ongoing collaborative initiatives between NIH and IASWR to build research infrastructure within social work; and 5) actions to be undertaken by national social work organizations to promote and facilitate psychosocial intervention research in social work.

Examples of Current NIH Research Priorities

-- NIMH and NIDA have current program announcements on developing behavioral and psychosocial treatments.

-- NIMH has a broad base of program priorities in the area of prevention, treatment, and rehabilitation. For example, NIMH is currently interested in prevention research that is strengths-based intervention-focused on the social and emotional development of infants, the prevention of depression and suicidal behavior among the young and elderly, and conduct disorder prevention. In services research (currently budgeted at approximately 70 million dollars), there are a broad range of priorities such as AIDS and the mentally ill, persons with dual diagnoses, effectiveness studies in primary care, and other human service systems. And there is great interest in family and community violence research and traumatic stress. All of the NIMH (and all NIH and federal agencies) priorities are easily accessed on the World Wide Web.

-- NIDA has program priorities in family and substance, gender differences, treatment of persons with dual diagnoses of mental illness and substance, treatment entry and retention, intervention in primary care and schools, community-based intervention and services, and AIDS-related research.

-- NHLBI and NCI have program interest in prevention and health maintenance behaviors, disease management, and testing psychosocial interventions to reduce depression, promote adherence to medical regimens, and improve quality of life outcomes following illness.

-- NIA has interest in research on caregiving and coping with stress, elder abuse, and grandparenting issues.

-- Other NIH institutes also have research priorities that coincide with social work interests, such as maternal and child health and development, stroke and diabetes rehabilitation and management, and family violence.

Intervention Research Priorities for Social Work

-- Multi-systemic interventions that include the person-environment interface as modeled in numerous clinical trials documenting the efficacy of multi-systemic family treatment and in the effectiveness studies of the strengths and multidimensional assertive community treatment model for the persistently and seriously mentally ill.

-- Multi-modal and combined interdisciplinary interventions that more closely model the complexity of human problems and strengths and of real-world service systems.

-- Effectiveness studies of interventions previously found to be efficacious in highly controlled laboratory-like conditions in relatively uncontrolled service environments that blend attention to internal and external validity, and include provider-defined samples and settings -eg. using usual care and other types of comparison groups versus intervention rather than traditional experimental control groups.

Actions to be Undertaken by Schools of Social Work

-- Facilitate doctoral students ability to obtain pre-doctoral fellowships and dissertation grants by ensuring that they receive necessary mentoring from experienced researchers.

-- Develop incentives and creative mechanisms to promote post-doctoral research fellowships.

-- Provide specific administrative supports to enable senior research faculty to mentor younger faculty.

-- Prioritize intervention research in faculty reward and incentive structures on the basis that it is uniquely time-consuming, but critical to a practice-based profession.

-- Administratively develop and support the development of research teams that are necessarily interdisciplinary and include adequate representation of experienced federally-funded researchers.

-- Assist faculty with the relevant skill and interest in successfully applying for federal mentored research career development awards.

-- Facilitate mentoring and collaborative relationships between social work faculty and experienced federally-funded researchers within and outside of social work.

-- Facilitate faculty receipt of research technical assistance opportunities.

Future Collaboration between NIH and IASWR

-- IASWR plan and facilitate NIH technical assistance workshops and seminars at national social work meetings.

-- NIH institutes explore targeted initiatives that would assist IASWR to build research infrastructure within social work, for example modeling the leadership of NIMH.

-- Develop regular lines of communication for consultation and information-sharing to help ensure that social work input is readily available to NIH program staff. It is particularly important that institutes of NIH are made aware of the critically need for research on the high risk populations served by social workers and of innovative interventions that merit further development and testing.

-- Jointly sponsor conferences on specific topics.

-- Collaboratively convene an interdisciplinary research symposium on a particular problem to model interdisciplinary and collaborative research.

-- Work to ensure that social work researchers are represented on NIH-sponsored task forces and working groups of OBSSR, and in and across specific institutes.

Action to be Undertaken by National Social Work Organizations

-- The National Association of Social Workers (NASW) Delegate Assembly officially identify research as a critical priority of the profession.

-- Jointly identify intervention research as a high priority and develop a collaborative targeted initiative on a substantive area to jump-start the necessary research infrastructure and professional committment.

-- Convene regional and national meetings on research in targeted areas.

-- Actively promote intervention research in professional journals.

-- Promote the role of social work researcher as a legitimate and valued professional role and responsibility.

-- Promote clearly identified research presentations at national meetings.