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.”
Theory of Roles*
Every role is a fusion of private and collective elements; it is composed of two parts,—its collective denominators and its individual differentials. It may be useful to differentiate between role-taking—which is the taking of a finished, fully established role which does not permit the individual any variation, any degree of freedom—role playing—which permits the individual some degree of freedom—and role creating—which permits the individual a high degree of freedom, as for instance, the spontaneity player. The tangible aspects of what is known as “ego” are the roles in which it operates. Roles and relationships between roles are the most significant development within any specific culture Working with the “role” as a point of reference appears to be a methodological advantage as compared with “personality” or “ego.” These are less concrete and wrapped up in metapsychological mystery.
Role emergence is prior to the emergence of the self . Roles do not emerge from the self, but the self may emerge from roles The hypothesis upheld by many that the genesis of role emergence and the genesis of language are one and the same is not tenable according to experimental role research. Long before language- linked roles emerge in the child’s world, “psychosomatic roles” operate effectively (for instance, the role of the eater, the sleeper and the walker). There is considerable psychic resistance against the intrusion of language in infants and even some resistance against gestural infiltration. There is no reason to assume that the language-free areas are non-human. There is overwhelming evidence that these silent areas are co-existent with the vocal ones on the human level and have great potentialities for independent growth. There may be forms of social communication without gestural involvement. The tele phenomenon operates in all dimensions of communication and it is therefore an error to reduce it to a mere reﬂection and correspondent of the communication process via language.
The roles of the mother, the son, the daughter, the teacher, the negro, the Christian, etc., are social roles ; the roles of a mother, a teacher, a Negro, a Christian, etc., are psychodramatic roles.
The term role itself comes from the language of the stage. Role playing may be considered as an experimental procedure, a method of learning to perform roles more adequately. The present popularity of the term and concept derives from the value it has proven to have as a training device in various social, occupational and vocational activities, and resulted from the initiative which the author has taken in developing them. It is through the study of roles in action that new knowledge about roles developed. In contrast with role playing, role taking is an attitude already frozen in the behavior of the person. Role playing is an act, a spontaneous playing; role taking is a finished product, a role conserve.
* See also “Two Schools of Role Theory,” p. 688-691. (in the same vol of “Who Shall Survive?”)
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.
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.
This post follows an earlier one: Psychological Eclecticism and Nothing And that posts is part of a series on a theme – that the psyche is a form of surplus reality created by language. This relates to the relationship between modalities, each one a shining a light on something ephemeral, the psyche.
However I’ve evolved my thinking. The language must be co created and that act transforms the relationship.
Naming roles has a measure of objectiviy when there is a consensus, but to reach that consensus means we really need to understand each other.
No role naming without role reversal.
I must tell the story of the High Priestess of Abundance.
Sherry Turkle has been a thorough investigator of the media – and I like her experiential – ethnographic approach in her first book Life on the screen – Amazon
We are in the early days of technology. Can we develop etiquette – a new norm in the way we have about things like eating with your mouth full. Will parents say, “Don’t put your phone on the table while we are eating.” ? It could happen. We changed norms around smoking. Around sexism. This interview begins to articulate new norms without being anti tech,