Recently, the phrase “evidence based pratice” has become ubiquitous. Those three words have appeared in multiple policy documents, government research directives, seeped into clinical and educational settings here, used on radio 4 there as a means to “advocate for the best for patient”.
On the face of it, there doesn’t seem much to object to – after all, who could object to basing their practice on what evidence suggests would be the best thing to do? Yet this question shows the rhetorical power of the use of language – as if to argue against evidence based practice would be to argue against evidence itself. I work as an dramatherapist, which means that a lot of my time is spent helping people to deal with painful or difficult aspects of their lives. In practice, this often means helping them to find imagary and poetics that express even painful and distressing situations to help them work through them. This means using a practice rooted in imagination – an imaginal based practice.
Henri Corbin coined the word “imaginal” to refer to the way that imagination has a reality of its own, different from material reality but real in its own way. He argued that what he called “the imaginal”is not done justice by the word “imaginary.” He said that to call things “imaginary” had a derogatory meaning, one that placed the contents of the imagination on a lower level. After all, who would trust a practice based on the imaginary? What would such a practice even look like? Well, in fact it might look quite a lot like evidence based practice, because evidence based practice itself is based on a set of fiercely held and passionately defended convictions that create the basis for imagining the world. Music therapist Kenneth Aigen writes :
“Rather than being dispassionate analysts of facts, scientists are passionate advocates for particular theories; these theoretical commitments strongly influence how facts are construed.” (Aegen, 2015)
Aegen here writes of something we instinctively know – a worldview has to be imagined before it can be proved, and that this process of imagining often forms a lens, like that of a contact lens that the eye itself cannot see.
Aigen suggests that it is not the idea of evidence that we need to oppose but rather the idea of what constitutes evidence. Proponents of evidence based practice have taken the word “evidence” and shackled it to a particular view of the world. They base this worldview on their creation of a hierarchy about what constitutes evidence. Thus “evidence” refers to knowledge gained only by certain methods. Researchers must take an objective as possible view to eliminate personal bias and place their pre-existing theories to the test. At the top of the pyramid of evidence lies randomised controlled trial, (RCTs) in which two identical groups are found, one is exposed to a treatment and the other not. In this way, one could measure the difference between the two, and discover whether say dramatherapy clients fared better than a similar group who had nothing. Again, this may seems like a reasonable way of finding out if something works or not.
But below the surface, we might begin to have reasonable doubts. After all, random control trials were designed to test pharmaceuticals not say, the healing potential of art and relationship. Everyone’s body, we might reasonably assume, will work in pretty much the same way. But dramatherapy works with the mind, the emotions, the imagination and how these become embodied relationally. These most definitely do not work in the same way for everyone. Furthermore, dramatherapy wishes to not just “do” something to it’s clients but to help them to become empowered within the therapeutic relationship. A dramatherapist wants their client to become more aware of how their own perceptions shape their world, and to help them imagine who they have been, who they want to be, and what stands in their way.
Aegen writes: “To understand perception requires us to understand how we act upon the world, not just how the world acts upon us.”
Social scientists coined the word “reflexivity” used to describe taking yourself into account in order to understand a situation. However, reflexivity means not just reflection on your self as an individual, but reflection on the wider sources of thinking. It means thinking about thinking, thinking about where you got your thoughts from and why. In this sense, reflexivity calls for closer understanding of the philosophy and the politics of knowledge and how they affect your thoughts and choices as an agent in a given situation. My status as a white heterosexual middle class man elicits a response from whoever I am with based on our shared sense of what this means between us, whether or not we consciously acknowledge it.
Much evidence based practice involves eliminating uncomfortable complexities like this, attempting to understand the whole world as a set of processes to be discovered, categorised and analysed. The brain seems quite good at this and loses itself quickly in abstract problems to solve. I work with children affected by family alcohol and drug problems. One reasonable question might be “ how are children affected by family alcohol and drug problems?” or even “do the children of alcoholics become alcoholics?” But if we stop for a moment we can see that we cannot really answer this question definitively. There can be no way of amalgamating all of the children of alcoholics into one category and finding out a definitive truth about this – one that truly answers the question. We could take a different approach, – like specialist researchers Forrester and Harwin, who ask us instead to think about a variety of generic cases – like an infant whose mother has been taking heroin, a 5 year old whose father and mother drink and who have violent arguments and a 12 year old sent to a public boarding school whose mother drinks every day.
Being given this narrative information immediately broadens out the sense of the problem – there is not and cannot be a “child of alcoholics” more like multiple occurrences of children and alcohol or drug problems with similar and different aspects. Language acts as a model of the world, rather than the world itself, and it constantly seduces us into believing that it is what it represents. When we fail to distinguish our models of reality from our experience of reality, we can easily fall prey to the hidden problems in the human psyche – the desire to use knowledge like a form of empire building, to establish and maintain privilege.
I am reminded of a quote from the philosopher Emanuel Levinas about his fear for philosophy – that it was “tantamount to the conquest of being by man over history.” One could quite easily substitute “philosophy” for “evidence based practice” and the same fear be expressed. Levinas suggests that at it’s heart what drives this enterprise would be a process very recognisable within relationships, one psychotherapists have long recognised – the desire to reduce the other to the same. What follows on from this is a research method unconsciously committed to the eradication of difference. This is not just limited to therapy. The worldviews that we live within and encounter continue to operates on dysfunctional principles.
All the suffering of the mind – the splitting, the narcissistic wounds, the anxiety, the need for control – all these and more define the cultural mind we operate within. They reappear in our workplace, our social institutions, our relationships with colleagues or managers, our attempts to find funding opportunities. James Hillman once wrote “the wound and the eye are the same.” The debate about what constitutes evidence takes place within a larger cultural mind that is also dysfunctional, where knowledge is used to seek power and approval, to defend against hostility and to maintain privielge and injustice. Aigen says that a review of music therapy research showed that seeking the approval of medical professionals who held the key to the public acceptance of music therapy was the primary factor in determining appropriate research methods and focuses.
Here we see a good example of how research not only investigates, but forms fields of power. Art therapists, who work with the poetic psyche, forced to reduce their work to a research method that cannot describe what they are doing. The pragmatic need for acceptance leads to a translation of the rich language of art into the narrow parameters of a preconceived notion of evidence. One irony about the current emergence of “evidence based practice” as an inescapable political necessity is that it has emerged anew despite decades of criticisms of it as philosophically naive and politically motivated – Nietzsche wrote in 1874 in criticism of the way research often finds what it wants to:
“When someone hides something under a bush and looks for it again in the same place, and finds it there as well, there is not much praise to such seeking and finding” (Nietzsche 1874/1993: 50)
Subsequent decades saw attacks on philosophically naive scientism from social constructivism, feminism and post-modernism. That evidence based practice has become talked up as a “gold standard” within a range of social institutions – not just psychotherapy but also social work, eduction, healthcare at precisely the moment in time that we witness a rapid new wave of liberalisation within all these sectors does not seem a co-incidence. As our society has become increasingly pathologised, therapy now can looks more like an opportunity to make money on a large scale. This means that psychotherapies and arts therapies face the challenge of companies looking to cherry pick “techniques” and then apply them to less qualified and less skilled workers at a cheaper salary.
By arguing that the relationship is what matters, therapies have been able to resist the grinding attack of such technical-rational economics. The current installation of evidence based practice bypasses the particularity of relational therapy to discover “what works” as if this something to be discovered rather than created. Once you “discover” what “works” then you can easily roll this out on an industrial scale. I see a direct connection between current uses of evidence based practice and the neo-liberalisation of public services.
So what then, of a poetics of evidence? As a dramatherapist, I argue for the importance of borderland disciplines. In ecology, the most productive and diverse areas are places where two different environements meet – the edge of a wood, or the edge of a pond have the most species and the greatest natural productivity. Dramatherapy exists on the borders of theatre and psychotherapy, of the body and the imagination, of the highly social and the deeply personal, of the mythic enactment and the kitchen sink drama. What I find missing in evidence based practice are the same uncomfortable realities we would like to ignore – the reality of social and economic privilege, the challenge to not reduce the other to the same, the power of imagination and the difficulty in interpreting it.
The challenges to all of us living in our technical -rational scientistic culture, where so called “evidence” is married to an aggressive neo-liberal economics seem strong and daunting. We are witnessing an ideology that sees profit everywhere, especially in places once considered public services.
However, during my dramatherapy training, my fellow trainees and I were being inducted into a different way of seeing. A way of seeing the images we carried, of enacting them, bearing witness to them, of giving the many different actors within the mind a stage to safely play their dramas out. I noticed how we seemed frequently drawn to create personal pieces of therapeutic theatre in which a small, seemingly helpless person faced a larger apparently indestructible monstrous force. A small child might be all that stood before a vicious and brutal monster. And the child would find the courage to say “You have no power over me”. Dramatherapists, who constantly negotiate the highly permeable threshold between metaphor and experience, know that imaginal based practice may be what all therapists, regardless of theoretical orientation, practice anyway.
The mind itself may be considered poetic, and its poetic nature a defining feature. We imagine before we do anything else and we do this to see, to shape and percieve the landscape before us. The trick may lie not just in knowing this, but in utilising this knowledge, this basic poetics of evidence. And the utilisation of poetics of evidence would mean making use of the way that perception creates poetry, that not only are the wound and the eye the same, but the wound and the eye form a poetic vision of the world. For what is the evidence of the wounded world around us? We can no longer afford the luxury of assuming that we observe the world at a distance, not affecting it or acknowledging how its dominant thought forms us. Climate change and the reality of environmental destruction offer evidence enough.
The roots of the word Poesis mean “making.” Here we see the tasks of a poetics of evidence. Our expressions re-make the world. We do this when we bear witness to our participation in the unflinching beauty of the world, its sorrows, its shadow, its vitality, its soul.
Aigen, K, (2015). A Critique of Evidence-Based Practice in Music Therapy. Music Therapy Perspectives, 33(1), pp. 12-24.
Forrester D and Harwin J, (2011), Parents Who Misuse Drugs and Alcohol – Effective Interventions in Social Work and Child Protection Wiley-Blackwell, Chichester
Levinas E, ed Sean Hand (1989) The Levinas Reader Blackwell, Oxford
Nietzsche F ed Shact R (1993) Selections Prentis Hall New Jersey