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?”
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.
“a role is the functioning form the individual assumes in the specific moment he reacts to a specific situation in which other persons or objects are involved” (Moreno, 1977, p IV)
Lets take a list of roles, these are from Max Clayton’s article (Clayton, 1994), it is a convenient list, and it is the one that got me to think about this:
Frightened, abandoned orphan
Anxious and suspicious fantasiser
For each of these there is as Moreno puts it: “a specific situation in which other persons or objects are involved.” We can grasp the role it is possibly in relation to from the role.
Frightened, abandoned orphan
Anxious and suspicious fantasiser
Art Materials or Audience
Wilderness, the unknown, adventurer
Compliant Follower, Sucker, victim
The Void, Black dog, Stubborn controller
Absent Parent, Threatening bully
Challenging person or situation
Creating Change in a Role Relationship
These role pairs will change as one of the roles changes:
The teacher can’t teach without the student
Lovers need lovers
If the manipulatee ceases to be duped and becomes assertive the manipulator can’t manipulate.
If there is no speaker, become a good listener.
If there is no artist, become an appreciative audience and contribute materials
Be loving and love may come your way.
Stop criticising, appreciate and praise and you won’t be with a self-doubter for long.
There are different types of role relationship. Max talks of complementary roles and symmetrical roles.
“The diagrams made it easier to be aware of the complementary and symmetrical role systems that developed with other people and of the fact that there was an increase in complementary role relationships. As ability to analyse, plan and enjoy life came to the fore, so those roles pertaining to intimacy increased. There was a welcoming of closeness and an interest in complementing what others were doing. The aggressive approach to others diminished and along with this a lessening of symmetrical role relations and of the competitive dynamic that is associated with these. There was also a development of a real sense of being a role creator. Previously there had been much more of a sense of being a mundane person. A look at the diagrams also confirmed the ability to create forms of expression through which life purposes could be fulfilled. The experience of being a role creator was accompanied by an increase in motivation.”
An example of complementary role might be speaker / listener – and this would increase intimacy, as max suggests.
Symmetrical roles can escalate and be competitive e.g. Talker / talker can become shouter / shouter.
But some symmetrical roles can be intimate lover/lover gardener/gardener
Clayton, G. M. (1994). Role Theory and its Application in Clinical Practice. In P. Holmes, K. Karp, & M. Watson (Eds.), Psychodrama Since Moreno (pp. 121–144). London: Routledge. Retrieved Tuesday, 9 February, 2016 from aanzpa.org
Moreno, J. L. (1977). Psychodrama Volume One (Fourth ed.). Beacon, New York: Beacon House.
This is an article I’ve been working on since I presented something along these lines at 2014 AANZPA conference. Its about the value of doubling what is adequate in the protagonist. Doubling is not coaching, but assisting the protagonist to say what is in them in a way that it can be heard.
It takes further the ideas I came away with from the Dan Wile workshop. He says something like this: I assist the couple to heave the conversation they would have if they were not fighting.
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.
Relational Psychotherapy, Psychoanalysis and Counselling: Appraisals and reappraisals [Kindle Edition] Del Loewenthal (Editor), Andrew Samuels (Editor)
In the light of the last post I’m keen to read this book and pleased its in Kindle format. The image on the cover is evocative! It shows well the potential for psychotherapy to create ambivalence in a relationship.
They seem fine. I’m surprised these branches of the tree are even needed – I would have thought that psychoanalysis and T.A. Were already “relational” in this way, i.e. Valuing of the relationship between the therapist and the client. Understanding attachment and early relationships as primary. Apparently not.
However I realise I’m in a different school altogether. One that see the relationship as the therapy, but not only the relationship with the therapist but the relationship people have with each other out there in the world. The marriage or committed loving relationship is the dominant one. I’ve come to understand that, especially in individual therapy, the relationship with the therapist can undermine the potential of the committed loving relationship with a partner. If there is no such relationship then the relationship with the therapist can be a surrogate, or if possible a way of facilitating the search for a mate. The rest of the time the therapist is there to facilitate the consciousness that will enable a committed loving relationship to be therapeutic. They are not naturally so – though they have a natural propensity to be so.
With this relational paradigm more and more fully grasped of late I see that psychodrama has something of this philosophy well developed. Moreno speaks a lot of “in situ”. I think of that as working with the actual here and now relationships in a group.
Psychodrama does not require a theatrical setting, a frequent misunderstanding; it is done in situ – that is, wherever the subject is found.
Who Shall Survive? (1978) P86
However Moreno is not clear on this – Later in the same book he speaks again of therapy in situ
… it can take an immediate form, in situ, that is, in the course of all activities in which the individuals are en- gaged, in the home, in school, at work, for instance the handicraft shop, steam laundry, carpentry shop, department store, etc . The situations of living and working are at the same time used as therapeutic settings. We have found, however, that the analytic and activistic forms of group psychotherapy are not applicable to the deepest disturbances of the individual and the group; they require the application of deep action methods in the form of psychodrama. But they are applicable to social problems of the group in a setting in which, during the treatment, the group is artificially cut off from the community as if the rest of the community were non-existent and as if the influence coming from it could be disregarded.
He comes close to a relational paradigm, and then moves away for “the deepest disturbances of the individual and the group” to theatre where psychodrama clearly becomes treatment of or via a protagonist. Yet he stays close, because as we know, … the protagonist is a protagonist for the group. (ref?)
The idea that the relationship itself can be the source and vehicle for growth and healing, is not explicit in psychodrama – it is there in most psychotherapy, but only in the relationship between the client and the therapist. Yet this idea that the protagonist is working for the group can be translated to the protagonist working for the relationship. That helps!
The relational paradigm is still to have its major impact, like any paradigm shift it is hard to get from the perspective of the old space.
Imago dialogue is one technique for activating relational healing, one that is easy to teach to clients. However I think T.A. Has the potential for that, Marshall Rosenberg NVC, and psychodrama does as well… Concretisation, role reversal, mirroring and doubling are potent methods. Psychodrama is not so easy without a director. How make the method easily accessible is what I’m working on all the time.
I had to get the book, it is a sort of meditation on the nature of the relational space. It focusses on therapy, but this would be so relevant for those of us who consider that the marriage is the therapy.
Loved the book, learned so much. Finished up disliking him more. Never liked him, always awed by his genius, and impacted. His attitude to his affair and his relationship with women is not just of its time – it is callous and a-psychological, out of touch and this is so disappointing. It shows a flaw in his professional as well as personal life, not one that I can forgive. I sort of knew this but here it is laid out – blatant. Even though the author seems to be sympathetic, colludes.
So I rate the book 5 for illumination and remove stars for an ultimate disdain for the character.
I am highly conscious of the language in couple therapy I do at the moment. I used to use the Imago language in couple therapy for many years. I was resistant to the rather ugly “sender and receiver” words. Though not as accurate for what was actually happening I preferred talker and listener in the last few years. However after listening to audios by Hedy Schleifer I’ve shifted to the “crossing the bridge” language of “visitor and host”. As one client told me, that is a bit fruity, whatever that means.
The thing is that is not just a change in language, but a whole different mode of being. Sending is a metaphor for posting something into space and it is then received like an email. This is not a metaphor that is very connecting. It also leaves the receiver wanting to respond… it invites reply. Responding is close to reactivity, and replies are close to argument and debate.
Host and visitor are quite different. Each person is having a turn at the same time, one as visitor, on a trip to another land, as a learner, a witness as an explorer a learner. The other as a host, a presenter, a storyteller. with this metaphor for the work there is not the same need to coach appreciations… I just say, be a good host and be a good visitor, and immediately they say such things as “Thanks for inviting me into your world, I appreciate you taking the initiative, I know it might not be easy for you.”
In the visit I use the exact mirroring , summary, validation and empathy structures.
In every culture there is some protocol and ritual for crossing the bridge into another persons territory or space. The protocols for visiting a neighbour apply. The leave taking can be quite lovely. I’ve heard people say.”Thank you for having me.” or more fully, such things as: “Thank you for inviting me, I appreciate you showing me how things work in your land. I will be much more aware how not to stomp on those areas that are so sore. I enjoyed meeting your little child and seeing how burdened your mother was while she had three under four.”
The language and the change facilitates dramatic enactment. Show me your world is an action cue for sculptures and role reversals with the social and cultural atom.
With maori clients and some other kiwis as well I have used some of the concepts from a meeting on a marae. The visitors are: manuhiri and the hosts the, the people of the land, the tangata whenua.
The depth of meaning of the pōwhiri or welcome could well be used to make the crossing into each others worlds more meaningful. For example the concept of Pōwhiri – the Māori welcome carries with it all the richness of the english word dialogue and more: “… po can be translated as a venture into ‘the unknown’ or a new experience, while whiri is derived from whiriwhiri meaning the act or experience of exchanging information and knowledge.