Pluralism, Practice-Based Evidence, and Practice Research Networks
I trained as a dentist originally back in Cork and spent 22 years looking at people upside down on my dental chair. In the early 2000s I went from ‘dental’ to ‘mental’ and trained as a Human Givens therapist. I have to say, I’ve found the world of the ‘mind’ more interesting than the world of the ‘mouth’, but as I reflect on aspects of dentistry I think perhaps there’s something to be learnt about practice-based evidence.
When I saw a new patient as a dentist the very first task was to ask about any problems or issues the patient was having, anything they wanted to see changing cosmetically, for example, or functionally, some improvements they might wish to make. The next job then was to map out exactly where they were now; what was there already in terms of their teeth and gums, a close inspection of their soft tissue, what restorations they had in place, did they have any pocketing around their teeth where the gums were loose, did the gums bleed on probing. I’d often take x-rays to see what I was unable to see with the naked eye. I’d even sometimes need to take impressions of their teeth to make plaster models.
Ok, are you still there? Or have you gone into panic as you ‘pattern match’ to some awful dental experience? Well, hopefully you’re still with me.
As I think back on these years of practice now I see what I was doing with my patients was establishing a baseline; where are they now? What is their starting point? I needed this so I could know where they were at the beginning of the journey with me and I would then be able to assess the degree of improvement in their dental health as we progressed through treatment to discharge. I’d also know when they returned for a check up months or years later what changes there had been since last time. I’d want to help them reach their goals, achieve their aspirations, solve their problems but all of this had to take place in the context of knowing where they were now.
Of course, I saw my patients individually, one by one, but I was also mindful around what influenced the choices I would encourage them to make. For instance, I’d be guided by the evidence on the best way to restore a root filled molar, or the best evidence about treating inflamed gums or which type of crown to choose for which situation. But, circumstances alter cases. In the end, I often would need to make a clinical judgement in the context of ‘this’ person sitting (well lying down) in front of me. And, most importantly, I needed to match my treatment with what they wanted, make sure I was aligned with them, checking in with them, obtaining their agreement on the chosen path. I would see my patients, one by one. Gradually, over the years, I built up a data-base of all those journeys and the knowledge I acquired from each encounter helped to inform the next encounter.
‘Ok Bill’, I hear you say, ‘come back to us. We’re talking about “mental”, not “dental”…’
Stay with me folks. Think about it. Is this not very close to what we need to do as counsellors and psychotherapists? Do we not need to know where our client is at now, at the beginning of our journey together? Do we not need to know where they would like to try to get to, or at least head in the direction of, or if they cannot yet feel able to articulate that maybe they can share with us what their greatest concerns are. And then, surely we need some way of measuring whether in fact they are moving in the desired direction and, indeed, if they are happy with our approach, if they feel heard and understood, if they feel they can engage with us?
For me, pluralism is about flexibility: to know that my own viewpoint of what I may think my client needs may not in fact match with what they want; flexibility to know that whatever tools or techniques or methods I trained in that make great sense to me may not in fact be the best choice for ‘this’ client in front of me, in spite of what the ‘evidence’ says; flexibility to be open enough to simply ask my client for their honest feedback around our connection and my approach as we go on our journey together.
We therapists and researchers can discuss, even argue about which tools are the right tools for the job of establishing that baseline, which measures to use, whether they are disorder-specific measures or wellbeing measures or general distress measures or whatever. But, the truth is, it’s NOT about the measures. For many years I’ve described measures as CETs (conversation enhancement tools). It’s often the story of a picture painting a thousand words. Sometimes a client can tick a box and tell me more than 15 minutes of conversation can. My clients can provide me with a road-map and compass to help me understand them.
What this means for me is through the systematic use of measurement with my clients I build up a lot of intelligence which allows me to reflect on my own practice, to identify my own strengths and areas of challenge, to guide me to maybe seek help in knowing how to better handle certain situations or scenarios. In short, I become a ‘research-practitioner’ able to call upon my own body of practice-based research to inform my practice. Just as I measure my clients’ baseline I can measure my own once I have a certain number of clients and I can learn through reflective self-supervision as I go along. But I can also know when to reach out, when to refer on, when to accept my own limitations.
Now folks, imagine taking all of that learning and joining it up with others, imagine the power of that collective knowledge. Never mind about small studies that have 20 clients in them. What about studies with 2000 clients? Here, this is the power of practice research networks. Practice research networks are collaborations of practitioners committed to using their work-based settings as laboratories for the generation of practice-based knowledge. This may involve a group of practitioners working together in a particular organisation, or practitioners who share the same therapeutic orientation and have a mutual interest in their results, or any group, no matter how large or small, that wishes to collaborate to learn together about their everyday work with clients in the real world of the front line of therapy. There are many examples of PRNs in many disciplines; including many aspects of medicine; paediatrics, nursing, and, of course, dentistry.
If you are interested to learn more about practice research networks, come to Bill’s online talk for CREST (University of Roehampton) on Wednesday 10th November, 6pm: Outcome and Feedback Measurement through a Practice Research Network .
Examples of practice research network studies
Andrews W, Twigg E, Minami T, Johnson G. Piloting a practice research network: a 12-month evaluation of the Human Givens approach in primary care at a general medical practice. Psychol Psychother. 2011 Dec;84(4):389-405. doi: 10.1111/j.2044-8341.2010.02004.x. Epub 2011 Feb 11. PMID: 22903882.
Andrews, William & Miller, Scott. (2012). The Development of a Practice Research Network and Its Use in the Evaluation of the “Rewind” Treatment of Psychological Trauma in Different Settings. International Handbook of Workplace Trauma Support. 213-226. 10.1002/9781119943242.ch14.
Andrews, W., Peter Wislocki, A., Short, F., Chow, D. and Minami, T. (2013), “A five-year evaluation of the Human Givens therapy using a practice research network”, Mental Health Review Journal, Vol. 18 No. 3, pp. 165-176. https://doi.org/10.1108/MHRJ-04-2013-0011