Community-Based Research: Creating Evidence-Based Practice for Health and Social Change
Marcia Hills, R.N., Ph.D.
Jennifer Mullett, Ph.D.
Community Health Promotion Coalition
University of Victoria
Victoria, BC, Canada
Paper presented at the Qualitative Evidence-based Practice Conference, Coventry University, May 15-17 2000.
Evidence-based practice usually refers to gathering quantitative data upon which to base decisions about what constitutes effective or efficient practice or what is sometimes referred to as “best practices”. The authors argue that, when gathering evidence about practice concerning people in communities which is often the case in the health sector, different evidence is needed and, consequently, different methodologies and methods for collecting that evidence must be used. In this context, the notion of basing practice on evidence raises the question “what do we accept as evidence upon which to base our practices that involve people in communities?”
I recall a social work teacher I had saying the main purpose of the training was to develop the professional identity of a social worker. I liked that idea. Especially once I saw that as a social worker I embraced a set of values, a body of literature and a community of practice. We valued a social systemic rather than individual approach, this meant seeing the world in quite a different way to, say doctors whose only systems were the human biological ones, who could make individual diagnosis but not social ones. Even better it distinguished us from psychologists, who adapted the medical model to the psyche, enviously creating a system of diagnosis based on the medical one.
Maybe it was a good thing at the time. There were variations on the theme, there were Christian social workers who I did not identify with and radical social workers who I did identify with. This blurred the edge between personal and professional identities. My family was not strong on identity. Atheist/Agnostic Dutch/Australian, humanist left rather than right. I must have craved a more defined identity as my first forage into this realm was to be able to say ‘I am a bushwalker”. In Sydney at the time, for me it had an almost religious existential meaning. Value words included intrepid, nature, hard, travelling light. It distinguished us from mere tourists, and I’m sure there are still people around who are part of that circle, and have let it define them to some degree. Now, 56 years later I retain some of these values. I trained first as a teacher but did no embraced the identity. Bushwalker softly morphed to mountaineer – but I saw it as an extension of my BW ID. Traveller was another extension I aimed to embrace, Peter Pinney style (See my blog post) but I was too much of a settler.
Philosopher, hippie, marxist were all on the journey. Now I’m writing a paper: “Being a Psychodramatist.” I don’t think I’ve landed in a fixed place. Identifying with groups and activities is one thing, belonging to a community is another, being conversant with a philosophy of life… All ok and maybe steps in the developmental pathway. As a trainer in psychodrama I want trainees to become psychodramatists, not just learn some techniques. To that end it is good to hold fast to a tradition and to embrace it. Not to cling to it, not to hide behind it. And the value in this particular tradition is that it is aware that the tradition is a conserve and that from a conserve we warm up to spontaneity and creativity. That is – from the old to the new.
Lynette Clayton wrote about the personality emerging from the roles we enact. Maybe it is also right to say that it emerges from the identities we embrace. Hmmm maybe the identities are things we discover in our selves, and then embrace. Over identification with a philosophy or group is a form of narrow mindedness, yet to be forever eclectic and skeptical is just confusing.
We need to develop an ego, personality, self, identity – all words, all useful especially in their respective philosophies. And there are stages of life for each.
“The teenager must achieve identity in occupation, gender roles, politics, and, in some cultures, religion.”
Thankfully he adds somewhere that this phase can go on for many years. And it is also clear that in his scheme there are many identities, professional being just one of them.
I think I developed a stable professional identity, did not get there till well into my 30s though. I see it as a cluster: psychodramatist, psychotherapist, counsellor, philosopher. Within that identity there is a lot of scope as well:
“There are more things in heaven and earth, Horatio, Than are dreamt of in your philosophy.”
In a way it does not detract from the pernicious psychological philosophy that is Trumpism.(I wrote about it here) He does not build his hotels either. And the ghostwriter Tony Schwartz, is now ashamed of his collaboration on the first book “The art of the Deal”. When I saw the list of book titles on Amazon by Tony Schwartz I assumed he was a perpetrator of the same philosophy – GCP – goal centred positivism, or psychological imperialism, or what Marx called idealism, the same standpoint a colleague called “The idolatry of quantitative methods in the teaching of psychiatry”. And I think maybe he was, maybe he still carries the dark seed.
But Tony Schwartz is more complex than just reading the titles suggests. Judging a book by its cover is a bad habit of mine. I still have not read one his books but I have listened to one of his talks on YouTube. It seems he understands one of the hallmarks of the “positive thinking” philosophy, the denial of the “shadow”. He even quotes James Hillman quite well on the need to embrace the shadow (though Hillman could not embrace his own). To accept what is, not just what you desire. He certainly is afraid of a Trump presidency.
Schwartz claims he wrote “The Art of the Deal”. I imagine that what is said in the Guardian is more the case: “In it he translated Trump’s coarse ramblings into charming straight talk”.
I have some hypothesis I’ll continue to investigate.
Schwartz attributes the problem with Trump to his “character”. He is a champion of the philosophy that Trump is a narcissist and a baddie. If he was a goodie then his positivism would be ok.
Trump is a victim at the success end of the American dream. He embodies ideology that is much larger than him, an ideology at the heart of the superstructure of the capitalist system. The rags to riches myth is meant to keep workers in their place, working hard, while they remain poor. Occasionally one of the rich believes the myth, that it is his own character that makes him rich.
Belief in being the biggest, the greatest, the best, the most successful etc. does “work” to some extent. I can imagine the US booming in the most crass and vulgar way, till it crashes and burns and maybe takes the world with it. It is not just Trump, he is the product of a system rotten at the core.
Trump is not a crazy narcissist. He is the product of a tradition of thought and practice. It may have started with Aristotle or Auguste Comte. Wonderful philosophers, they transcended superstition in favour of rational thought, but they carried a dark seed: they saw the world as a machine as something we could understand, and manipulate. The machine is also divine when weird mysticism can make more money.
What is this school of thought? I’m calling it Goal Centred Positivism. GCP. The Learning Annex is a significant promoter of the philosophy and the evangelists. Strains of this mode of thinking are everywhere. It needs to be identified and addressed in many professions and many world views.
What is bad about GCP? To name this is harder than it looks. While it has instant appeal in its simplicity and commonsense, it is a lie. Not everything is as it looks on the surface. There are limits to thinking positively. Like in The Apprentice — Trumps (fake) reality TV show there is always one “winner” and many who loose, who are fired, who are losers. Life is not a game. Respect for the roots, i.e. being radical, going deeper, seeing the whole picture, beyond the simplistic goals.
GCP is very American, Napoleon Hill was an advisor to two presidents of the United States of America, Woodrow Wilson and Franklin Delano Roosevelt.
The rise of Trump (may he soon fall) has revealed deep social, political and financial schisms and fault lines. It has also revealed this schism in world views prevalent in therapy and personal growth.
I’m writing this here in my blog that is also about personal development and psychology. This goal centred positivism has brushed many schools of more reputable psychology. It is probably present in some way in most. The most blatant example is Behaviour Modification. It is central the frame works set by insurance companies who fund counselling and therapy. It is so important to distinguish life giving schools of thought from this dark flow. What is the antithesis of goal centred positivism? Approaches that have one of the following ideas at their centre:
Trump represents the power of a pernicious world view, it is important to understand the tradition and oppose it. Opposition does not come easily to the liberal, meaning centred approaches to change. Lets clearly distinguish true personal development from the crass version.
Not sure if this really Seneca’s take on Anger. It interesting though. The essential take on anger is that it is the result of holding unrealistic expectations and that more pessimism will help calm you down.
Anger is a philosophical problem with a philosophical solution. Perhaps a bit like CBT?
My philosophical response is that it is not sufficient. Unrealistic expectations can equally lead to sadness and then it is usually framed as disappointment. However there is something to this philosophical take. Our thoughts not the other persons behaviour are at the root of anger.
A fuller take on this idea from Marshall Rosenberg:
In short: Anger is the way we get a signal that there is an unmet need. I think he uses the example of the “check engine light”.
I’m aware of another form of anger that is not really either of the above. Anger at injustice. this is from wikipedia: “Socialism is the flame of anger against injustice.” I think of this being tied in with our fight response, adrenalin rushing to survive against onslaught. This not just in the eye of the beholder as some might say. Inequality, sexism, racism, exploitation and oppression really do exist. There is a good fight. Anger at violation of human rights surely is a good thing.
Question: “How can I know for sure that my anger is righteous indignation?”
Answer: We can know for sure that our anger or indignation is righteous when it is directed toward what angers God Himself. Righteous anger and indignation are justly expressed when we are confronted with sin. Good examples would be anger toward child abuse, pornography, racism, homosexual activity, abortion, and the like.
Makes sense if you think God is against gay rights and women’s right to choose. But it does not make sense in the real world. Investigation is the key to knowing waht is real.
Anger and Psychotherapy
I’ve heard this a lot in my profession:
“Anger is a socially suppressed emotion and people – especially women – need a safe place to get in touch with their anger. Expression of anger leads to discovering the emotions under the anger, being assertive and getting needs met. Anger is not the same as violence.”
The trouble with this is that it does not work like that if the person comes home and thinks it is a good idea to be angry with their partner. In some way anger can easily lead to violence verbal, emotional and physical. Marshall Rosenberg’s principle that other people are not the cause of our anger needs to be taken into the picture more fully than it often is.
It is easy for a therapist to side with the person in front of them. To see their side of the story. Much harder to concretise the “other” in the room with the other perspective.
In psychotherapy with couples the question about the nature of anger is important. It is held by many couple therapists that people who choose to be together in an intimate relationship are in a “horizontal relationship”. The tenet is that as therapists we should not take sides, but be a catalyst to the healing potential in the relationship. From an Imago website:
Romantic love is the door to a committed relationship and/or marriage and is nature’s way of connecting us with the perfect partner for our eventual healing.
In my work with couples I can hold that trust that the couples are equally wounded and that the power struggle can be nasty and that they have equal responsibility to get out of it. Each partner can take full responsibility for the relationship.
Talk so the other will listen.
Listen so the other will talk.
Even when there seems to be abuse of power, it usually does not take long to get to the fear, hurt, powerlessness and vulnerability under the surface. All problems in the relationship are co-created. i.e. the way one partner talks leads to the way the other listens – learn to talk without blaming shaming and criticism. Learn to listen so the other will talk. Even social inequalities can be addressed with this principle. I’m amazed how far I can take that principle in my work with couples. I’m amazed because I don’t think society is an even playing field.
Look at the list here “160+ Examples of Male Privilege in All Areas of Life”. This social inequality seeps deeply onto marriage and committed relationships.
Michael White years ago drew my attention to a Gregory Bateson idea: there are “restraints of feedback and restraints of redundancy” The feed back ones are created on the level playing field.
The other restraint is due to the social values that are the ruin of a relationship.
The biggest problem in couples therapy, beyond the raw incompetence that sadly abounds, is the myth of therapist neutrality, which keeps us from talking about our values with one another and our clients. If you think you’re neutral, you can’t frame clinical decisions in moral terms, let alone make your values known to your clients. That’s partly why stepfamilies and fragile couples get such bad treatment from even good therapists. Stepfamily life is like a morality play with conflicting claims for justice, loyalty, and preferential treatment. You can’t work with remarried couples without a moral compass. Fragile couples are caught in a moral crucible, trying to discern whether their personal suffering is enough to cancel their lifetime commitment, and whether their dreams for a better life outweigh their children’s needs for a stable family. The therapist’s moral values are writ large on these clinical landscapes, but we can’t talk about them without violating the neutrality taboo. And for clients, there’s the scary fact that what therapists can’t talk about may be decisive in the process and outcome of their therapy.
I think this is tricky terrain. I think it best to focus on the co-creation of the relationship rather than the unequal society it is born from. That is a value I have because there is a lot a couple can do to address these issues in their relationship IF they can connect.
Still I am pleased to have the “permission” to have values, to weave them in in such a way that I am not seen as taking sides, because I am not.
Psychodrama and sociodrama. Psychodramatic roles and social roles. What is the difference?
Understandings I have about what is not the difference: Psyche is “inner” and social is “outer”.
Psychodrama is about social and cultural atom. Is there a psychological atom? I don’t think so.
I have a story that the might be a clue about when the psyche is at work. This happens often, and again recently I co-led a group. We spent an hour or two warming up to the group (we had little idea who would be there). We made a good connection. One way was that we enjoyed discussion was about anger, how to work with it in a psychodrama? The other fun thing was sharing the tv programmes we liked.
The first words in the group were how to deal with anger. And the first drama had quite a focus on Netflix.
I have always put this down to there being a sociometric matrix at work. It does seem like Jung’s synchronicity and “objective psyche”? Even when we use the word psyche for that it a SOCIOmetric phenomenon I think.
Psychodramatic – and psychological have the greek word soul for soul at their root. The breath, the butterfly. That which has little material weight, like images, imagination, stories, fantasies and dreams. These things are deep in our being our history, archetypal… and some way collective, they come alive in art, language and theatre.
I keep coming back to psyche is social. Or to make more sense, the social is psychological. The social can be seen as the space between, as the image as the soul, or the heart.
A sociodrama has a sociodramatic question.
A psychodrama has a concern.
Both are questions about life, the psychodramatic question is more about individual dilemmas and healing. A protagonist can do the work and others can learn from that for themselves so a psychodrama usually has a protagonist. However the question can be tackled by the group, it is then a psychodrama is group centered.
A sociodramatic question is about the group, the world, about US. So Mostly a sociodrama does not have a protagonist. But maybe the question is best explored by a person who is living that social dilemma, then Walter have a protagonist centered sociodrama.
A useful distinction but not enough.
Both are drama, both bring to life something of the soul, perhaps the soul of the world, or soul in the world. Both can concretise the imaginal, possible futures hidden images.
Some moments in sociodramas I recall were exquisite moments theatre. Moving and uncovering the depth of life. Full of soul.
Maybe it is not useful to make any hard and fast distinctions about the socius and the psyche. Both are there as we seek to explore ourselves in the world.
In a group it would be helpful to move freely along the psychosocial continuum.
According to Michael Onyebuchi Eze, the core of ubuntu can best be summarised as follows:
“ ‘A person is a person through other people’ strikes an affirmation of one’s humanity through recognition of an ‘other’ in his or her uniqueness and difference. It is a demand for a creative intersubjective formation in which the ‘other’ becomes a mirror (but only a mirror) for my subjectivity. This idealism suggests to us that humanity is not embedded in my person solely as an individual; my humanity is co-substantively bestowed upon the other and me. Humanity is a quality we owe to each other. We create each other and need to sustain this otherness creation. And if we belong to each other, we participate in our creations: we are because you are, and since you are, definitely I am. The ‘I am’ is not a rigid subject, but a dynamic self-constitution dependent on this otherness creation of relation and distance”.
I found a few pages in Psychodrama Vol I by J.L Moreno – I think this item was written well before 77 when the book came out – a Symposium in the 40s?
Moreno talks of the individual locus of physical ailments. There is another locus for psychological work, the relationship.
Then he gets really radical. The relationships in life are therapeutic. The psychodramatist activates the healing potential of the relationships.
And then there is one more thing!
“the medium of therapy [is separate] from the healer as well as the group therapeutic agents.
What is that “medium” – Moreno in other places calls it the sociometric matrix.
Here is how I sum up Moreno’s philosophy: there is a network of social and cultural role patterns we are born into. Born out of perhaps, that is the matrix. Spontaneity is our ability to transcend that given.
Somehow I found this book and purchased the Kindle edition It exactly relates to what I’m thinking about about the moment.
As I’m grappling with psychodrama and the relational paradigm, it is good to find someone who has grappled with this in Gestalt. Gestalt is in some ways born out of psychodrama, though it has from my experience been far more “individualistic”, it is individual therapy in the group, and then there is that Prayer by Perls! I have no doubt that Moreno pioneered a relational conception of reality (see Zerka Moreno on Doubling and Tele and The Locus of Therapy – Moreno, but that it was still somewhat rooted in the individual paradigm. Perhaps Wheeler & Harville Hendrix came to this specific consciousness separately?
History of the old paradigm
I’m reading it slowly and want to catch the nuances of his version of the relational paradigm. The first section is about the history of the old paradigm – and summed up in the quote below. (Wheeler, 2000, pp 52-53)
Is there no individual at all? Or is it a figure ground thing? Is the old paradigm absorbed in the next? What does he make of Buber? How does his perspective impact on practice?
The Individualist Paradigm
All this is the expression of what we have already begun calling here the paradigm of individualism, a complex and interlocking set of underlying assumptions and hidden presuppositions that has a 3000-year pedigree in the West, running straight back to the Greeks and then forward in a largely unbroken line down through the Hellenized Hebrews, the Christian synthesis and its medieval flowering, the Renaissance with its rediscovery of humanism, the Enlightenment, the 19th-Century age of scientific materialism, and right on down to our own post-modern times. In the process this paradigm serves to unite thinkers and movements as otherwise diverse as Plato and the Hebrew Prophets, Galileo and the Church, Freud and the Behaviorists, or Carl Jung and Karl Marx, all of whom may disagree vehemently and sometimes violently with each other about the dynamics and determinants of human behavior, the direction of history, the motivation and purpose of life, and so on — but all of whom are united at this deeper level by underlying assumptions, taken for granted but seldom articulated, about the nature of the individual self, which is to say, who those individual human beings are who are living that life, and having or creating or submitting to those experiences.
The fundamental propositions of that paradigm, as we have already seen and as we lift them out now for examination, are: 1) that the individual is prior to relationship, and exists in some essential way apart from relational context and connection, and 2) that relationships themselves are therefore secondary, and in some sense less real than the individuals who enter into them, who after all were already there, fully formed, and can come and go from one relationship to another as their own needs and circumstances dictate, presumably without altering their own essential nature. To Plato, as we have said, these propositions must have seemed incontrovertible and probably too obvious to bear mention — as indeed they may seem to us, on some purely logical level anyway, even if we do feel some nagging discomfort with them when they’re presented in this bald way — a hesitation growing perhaps out of living or working with infants and children, out of spiritual concerns or experiences we may have had, from intimate relationship and deep commitments, or just from our everyday experiences of living with and caring for other people. The fundamental separation of one individual’s experience from that of another, which follows directly from these assumptions, would likewise have seemed obvious to Plato — as would Descartes’s classic separation of mind or self from body, which was essentially unchanged from the Greek view, only some two thousand years later. The soul, which is the essence of the person, is individual, eternal, and unchanging — and of course separate from this material world, again by creation, which again closes off developmental or relational questions.
Wheeler, G. (2000). Beyond individualism: Toward a new understanding of self, relationship, and experience (1st ed.). United States: Analytic Press,U.S.
Facilitating interaction was the dictum I used for the first couple therapy I did. I recall, as an untrained social worker in a hospital being asked to work with a couple who had difficulties. The night before I read a gestalt based book on couple therapy and facilitate interaction was the central practical guide I took away. I could have done worse.
I have written on dialogue and encounter in the AANZPA Journal more recently: The Imago Affair. Let me quote a relevant chunck from that paper as I wish to further reflect on encounter.
At their heart, both Moreno’s and Hendrix’s work go beyond technique and are an invitation to a profound experience. The aim of a dialogue is not a specific outcome, nor is it reliant on one method. Here is the section of Moreno’s well known poem that encapsulates the idea of encounter.
A meeting of two: eye to eye, face to face.
And when you are near I will tear your eyes out
and place them instead of mine,
and you will tear my eyes out
and will place them instead of yours,
then I will look at you with your eyes
and you will look at me with mine. Moreno
Harville Hendrix introduced the validation step into the Imago structure with an eye to facilitating just such an experience. It is often taught as understanding or making sense. The lead-in line goes like this: “You make sense. And one thing that makes sense is…” The listener is invited to cross a bridge into the world of the other, and to see what they see, and feel what they feel in that world. Note the similarity to Moreno in Hendrix’s idea.
Buber clarified for me that a “Thou” relationship with others required honouring their “otherness” as an “I” distinct from me and any concepts I might have of them. This required a willingness to look at the world of another through his or her eyes. Hendrix
Linger on the moments of connection described here:
I will look at you with your eyes (Moreno)
look at the world of another through his or her eyes (Hendrix)
Are they the same?
Both Imago and in the work of Moreno there is the idea of a special meeting. Not just any meeting, but something profound, where you become the other…
How to facilitate, or operationalise encounter is different in the psychodramatic sphere than in the I Imago sphere. They use different contexts for their techniques as well, psychodrama: the stage. Imago: the couple in dialogue and Hedy Schleifer has a variation: Host / Visitor to the other’s world.
There are techniques/concepts in these modalities that are sometimes akin, but differently nuanced, and sometimes unique to the method. There are other modalities and have techniques for interaction, of importance is the variation of Imago developed by Hedy Schleifer and her husband, and the work of Dan Wile.
My friend and colleague Dan Randow and I are working on describing the varieties of techniques for encounter. Here is a beginning.
Here is a list of techniques/concepts:
Doubling: in Psychodrama
Mirroring — Psychodrama
Role reversal — Psychodrama
Doubling in Imago: Related to the use of lead-lines
Doubling in Dan Wile’s CRT
Mirroring in Imago
Empathy as used in Imago
Host, Visitor (Hedy Schleifer)
How does role reversal relate to encounter? In role reversal and in doubling you become the other to the best of your ability. You take the physical position of the other, quite literally in role reversal and by being alongside and slightly behind the other when doubling.
Is it useful to distinguish the inter-psyche from the intra-psyche; what goes on in our subjective world and what goes on between us? Maybe sometimes, all these encounter processes aim at improving the relationship and healing and growth of the individuals at the same time.