Evidence based practice – the chicken or the egg – which came first?

The Chicken or the egg, which came first?

Before you can have an evidence based practice you have to have a practice upon which to base your evidence.

If you only have 1 practice there is no opportunity to compare and contrast and establish a better practice. Without a better practice,  there  can never be a best practice and best practice, as a superlative,  is an illusion, it exists only, if at all, in a moment of time.

Our practice is 21 years old and it flies in the face of a great deal of “traditional practice”. We reckon it is pretty damned good although there will definitely be improvements which can and should be made.

Fly in the face number 1

Coming from couple counselling backgrounds we knew much more about couple relationships than we did about the politics. We knew very much more about the interactions between men and women than we ever did about criminals. So although we accepted the UK DV figures of 1994  that only 4.9% of DV was attributable to women our course was designed to work with male abusers but without excluding female abusers.  So, for 21 years we’ve worked with male abusers and female abusers, in mixed gender groups. Internally there have been very few problems with this. Externally you’ll perhaps be able to imagine the troubles! About 1,000 men and 100 women have completed the 36 hours of our programme.

Fly in the face number 2

We went for a closed group. We recognised that when John Doe from family X meets Sheila Oz of family Y  there will be many differences in their expectations – based on what they learnt from their family of up-bringing.   If someone, very reasonably,  only knows their own family then he or she  will tend to believe that all families will run like that.  Meeting people from different families will help him or her  to understand some of the differences.

We want the clients to talk together, as much as possible,  intimately. We want them to exchange as much information as possible about one another. Like women on labour wards, through the sheer intimacy of the situation some of the men and women will make friendships which will last and be mutually supportive.   We felt enormously supported in 2012 when we met Dr Louise Dixon whose very critical paper of RESPECT – the accreditor of perpetrator programmes in the UK – coincided with our practical understanding of their nonsense, and also her conclusions about similar work being needed by females  also matched ours.  (It has also been very refreshing that so many of her ex-students have continued to contribute to the greater reality of the IPV agenda.)

Fly in the face number 3

Emotion drives behaviour, not, in the vast majority of cases, a desire for power and control – read Ellen Pence’s 1999 confession about her notions of power and control ! Duluth and Beyond.

As clients talk about their emotional experiences in their families in a very large percentage of cases what pops up?  Well, yes, you guessed it,  as the research tells us, their own abuse at the hands of their parents, and others.  And what does that “put the client in touch with” ? – Their own sufferings, which when they explore and understand a little also brings their own behaviour, often in front of their children, into stark relief.   Most of the people we work with are seeking to regain (or keep) contact with their children so it is important that they understand the impacts of parental behaviour on their children (as well as their partner). The “emotional wheel”  provides a very much better focus than the power and control wheel:  it is immediately relevant to the clients themselves, their children and their partner.  Clients “take it on board”  with alacrity – rather than having the power and control wheel welded onto them, somehow.   (Our emotional wheel version differs a little from Plutchnik’s; rather arrogantly we think ours is better!  Open to debate!)

Fly in the face no 4

The amount of time and the format. Traditionally counselling runs an hour, 90 mins, 2 hours per week.  We want to run a closed group. Over longer periods of time people fall ill, get conflicting appointments, etc . etc.  A prolonged  closed group would disintegrate with drop-outs! Training for professionals very often occupies full days. The most important course I ever took lasted 4 whole days.  Men work.  Many men work moving shift patterns. You cannot satisfy all the various needs but you do need to be satisfying most.  Men provide.  If you “stop them from working”  you stop them earning and this interferes with many men’s ideas of their roles as providers. So you avoid that as far as possible. We work at weekends, Saturday and Sunday, 2 weekends, about 1 month apart. The results – 90 – 95 % of the people complete all the work.  This year we’ll work 32 of the 52 weekends – that is a very high social cost to us – we feel like martyrs!  – but the real importance is for the clients who can engage, and in the longer run for the benefit of their children and their partners and their future partners, too.  If we ever totalled them up it would seem like a very small cost to us, compared to the benefit to most of them.

Fly in the face no 5

In the UK 7 Duluth-style programmes run by 4 Duluth-style projects could scrape together 36 whole male figures on whom to base £1.2 worth of research, MIRABAL. The researchers drew some percentage style conclusions in the executive summary which lead you, if unwary,  to think “Wow  – that’s impressive!”  On page 8 of the fuller report you get the explanation – based on 36 men!

That year, our little organisation completed work with 55 men, 33 of them referrals by social services. So far, 12 months later,  we have heard of 1 man from that cadre that has been violent again.  I would bet that more than 45 of those men would have been willing to undergo the research afterwards. Our annual income?  Less than £15,000.   Buy some research with that!

We have a practice. We have some evidence but nothing like enough. Our independent evidence mainly focusses on the profound changes brought about in 1 client who would have almost certainly been concluded as having a “severe personality disorder”  although those words were not written. The examining psychologist’s remarks – 13 years ago – were:  “That condition is not supposed to change, they’ll have to re-write the text books.” A client who completed this weekend showed many of the same signs of very profound changes (and of course there was another who showed relatively little sign of change. )

Professor Daniel Siegel and many others have been doing just that, re-writing the text books, that is –  and no doubt his definitions of The Mind and emotions and their inter-relationship with the brain and relationships will, no-doubt, earn him a Nobel Prize or some equivalent in the future. For all of us “professionals” who became skilled at applying the various DSM’s diagnoses and, in our training, didn’t get any information about “the mind”, 95% plus of us to all appearances, Siegel’s work is likely to help us develop understandings of what constitutes a healthy mind, as opposed to merely diagnosing an unhealthy mind and then having very little idea about what to do with that to help improve the individual’s situation!

Emotion is a noun but with Siegel’s insights based on his definition he states : “emotion is a verb”. Temper is both noun and verb, more the latter than the former!

Evidence based practice.  Practice is a noun: unfortunately the verb is with an s!   How does evidence based practice practise?  Does it get trapped by attempting to apply a diagnosis without knowing what it is seeking to achieve?