Scholarship and Practice
“There is a 50/50 chance she will try and kill herself today,” the psychologist reported. I was the Manager of a National Health Service (NHS) programme working with young people with substance misuse issues, and this colleague had reported back to me on an appointment that had just taken place between a 15-year-old female heroin user and a Consultant Psychiatrist who was responsible for prescribing. The Consultant had not read the client notes and had conducted the meeting in such a way that the client fled the room in a state of distress. This client was highly unstable emotionally and had a history of suicide attempts. She was homeless but would stay with her 23-year-old boyfriend who was also an injecting heroin user. Her life was extremely chaotic.
When my colleague spoke to me about what had happened, I remember feeling frustrated and alarmed. Here was a highly trained and well-paid Consultant taking short cuts. This client had a history of difficulties working with ‘professionals’ and understanding this backstory and her general emotional state was important for working with her effectively. To make matters worse, I had previously expressed my concerns to the Commissioners of the service that parachuting somebody in once a week to do prescribing may not be the best approach when working with these vulnerable young people where building a trusting therapeutic relationship seemed so important. Even though many of my team were support workers who were not highly qualified or well-paid, they had excellent engagement skills and built good alliances with these young people that allowed them to work through the difficulties that had led to their drug use. They cared deeply about these individuals and it showed me that being highly qualified did not equate to being highly effective.
That day caused many of us in the service a great deal of anxiety. The psychologist who had brought me the news spent all day trying to locate her and eventually managed to contact her and calm her down that evening. Fortunately, she did not take her life but it was a genuine possibility that day knowing her fragile state. It was a critical incident that made me reflect very deeply about our practice as a service.
For these vulnerable young people our intervention literally could be a matter of life and death. As a consequence, I started a review of the service with my team and reported my concerns to Commissioners about what had happened. I asked the fundamental question, ‘Why do we do what we do?’ I thought about what would have happened had this young person taken her life and imagined myself being in a legal hearing answering questions about why we did what we did as a service. In truth, I’m not sure I had an answer at that time.
We operated by modelling ourselves on adult drug treatment services and Child and Adolescent Mental Health Services. We paid attention to the guidance and policy in our practice area although this was patchy at that time. Mostly we operated somewhat intuitively based on the experience and skills held by the team. Two were nurses, one of which was trained in Family Therapy. Four other staff were outreach support workers who used a variety of general support approaches with some motivational interviewing and cognitive behavioural therapy techniques. One of these support workers was a qualified psychologist. Our monitoring suggested that we helped a lot of young people and we even won a prestigious Government Home Office award as the best drugs team in our region. We were invited to a national awards ceremony in Westminster with celebrities and Members of Parliament where we watched a video presentation the Home Office made about our service.
I remember sitting there thinking, ‘Wow, we seem amazing!’ but also thinking about the weaknesses and stresses our service faced daily. The video was not a true depiction of the service, just a glossy snapshot of when we got it right. I have no doubt we did some excellent work and truly helped a lot of young people, but I could not stop thinking that how we operated seemed to happen more by chance rather than deliberate design.
I also became concerned about those who did not successfully move through the service. There were some who would engage for a few weeks and then drop out. There seemed to be a belief amongst staff that when clients did this that it was because the client was not ready to engage in treatment. Readiness for change is an important factor in addiction treatment (Prochaska and Velicer 1997; DiClemente et al. 2004) so this is a reasonable assumption for staff. But in such circumstances, we always assumed that the outcome for such a client was neutral, we never considered that the outcome of our contact could be negative.
What I learned from the story of the girl storming out the service was that it was possible for these vulnerable people to end up worse off because of our intervention. As a team we were well-meaning, committed, had a level of skill and were genuinely trying to help, but that did not mean that we couldn’t unwittingly contribute to decline in a client’s well-being if something about our practice and approach was poor. This was a lightbulb moment for me and has shaped me as a practitioner and academic ever since.
At that time, I was doing my first ever postgraduate study, a diploma in addictive behaviour with a prestigious University Hospital in London. I had time to think and reflect about what we did as a service during this course. I had access to research that was rarely available to practitioners due to costs and was introduced to a repository of useful journal articles discussing the issues I had become concerned about. It was the first time as a practitioner I had thought about what I do using genuine critical reflection.
Journey into Academia
My experience in practice and the study I engaged in started a journey that led me to work for a University and complete a PhD that looked at evidence-based practice with vulnerable young people. A journey that was a complete surprise to me because I certainly never thought of myself as an academic or academically inclined. I very much view myself as a practice-focused academic. It is the thought of trying to improve practice for the kind of people I used to work with which provides the main motivation for the work I now do.
If I’m really honest though, even now after thirteen years in higher education where I obtained a doctorate and became a Senior Fellow in the Higher Education Academy, I often feel like I don’t belong. I feel like an imposter especially when I come across highly intelligent colleagues writing for prestigious journals with consummate ease. Despite my achievements, academic work does not come naturally to me apart from my ability to present to audiences which I absolutely love doing. Study and writing is a challenge. I did okay at school but not great.
My father passed away when I was 12 and school didn’t seem important. I remember vividly my first day back after a period away as I grieved. A French teacher shouted at me because I did not know what a particular verb was in a particular tense. I remember him saying, “Why don’t you know this?” He had a scowl on his face and real venom in this tone. I remember little bits of spit coming out of his mouth as he raged at me. I looked at him, a bit choked up, and replied, “This is my first day back after my dad died.” He had failed to notice that I had not been present in class for six weeks! I could not answer his question as I had not done any of the study that would allow me to know what he was talking about. I felt humiliated and angry and from that point on I disengaged from school.
I spent the next four years messing around and doing as little as possible. This resulted in poor grades and report cards that were less than complimentary about my effort. Over time I started to believe them. I started to think, ‘I’m rubbish at this school stuff’. I forgot all the comments I had as a boy saying how bright and engaged I was. Now I was the stupid one who didn’t try. In my final year, having already significantly narrowed down my qualification possibilities, I did miserably in my mock exams. It was a wake-up call for me as I still needed to leave this horrible school and find employment and for three months, I got my head down and worked hard.
I sought support from a youth worker with a First-Class Honours Degree in engineering. He taught me, in a handful of sessions, all the Mathematics skills I should have learned in five years. This was one of several qualifications that turned from a failure into a pass. Despite this effort, the overall outcome of my schooling was a very modest set of results. I think it’s that experience that even now means, as a writer and researcher, I feel like a fraud. I left school at 16 feeling glad it was all over with. I did not feel intelligent in any kind of academic way and I certainly was not interested in any more study. Instead, I went to work for insurance companies for three years, something that I did not enjoy. Then my career took a different path. Inspired by the person who helped me through my exams, I started doing voluntary youth work. This led to a series of jobs working with young people and the wider community and eventually resulted in specialising in substance misuse work and my job in the NHS.
I discovered something I was good at and enjoyed. I was determined to help these young people navigate the difficulties of their teenage years successfully and realise their potential. I was passionate, I related well to these young people and I was highly creative in the programmes I delivered. What was interesting though was I was not qualified and never undertook any formal youth work training. I was someone who learnt from experience. If I studied, it was informally as I looked to learn lessons from those who seemed good at their job. I observed closely how they did things and what it was that generated positive responses. I was always trying to work out how I could do things better and always looking for new and creative ways for engaging young people effectively.
In truth, I was a little cynical of those who were qualified. I was often extremely underwhelmed by their practice and imagination. I found many a bit snobbish because they had some status that I did not and as I developed my career into substance misuse treatment, I found some social workers particularly (as what I would describe as) a bit up their own backsides!
As someone who is now involved in the journey of nurses and social workers becoming qualified it is an interesting journey to reflect upon. The label, status or qualification has never interested me, even as an academic helping people to attain such things. What drives me is a desire to improve practice with the vulnerable people I used to work with and perhaps once was.
I have moved from being a cynic to an advocate for education and training. My academic journey has given me a better sense of how to find useful evidence that informs and improves practice. I often think that I would be a significantly better manager and practitioner now than I was before my academic career and having done a great deal of study. I have learned so much that I wish I knew back then and would like to share some of these lessons. Nevertheless, one of these lessons is something I discovered long before my academic career. Experienced practitioners often have considerable wisdom. They understand the subtleties of effective practice and are an excellent repository of knowledge. Reflecting on my practice and academic journey, here are some things I’ve discovered that I think are important for practitioners to consider.
Harm that is induced by treatment itself
When studying my first postgraduate qualification and whilst still working as a service manager, I first came across the idea of iatrogenic effects. An iatrogenic effect in medicine is when a planned treatment inadvertently causes a negative or poor outcome (Huefner et al. 2009). The term literally means “physician caused” (Bootzin and Bailey 2005, p. 872) but is often more broadly considered as “harm that is induced by treatment itself” (Moos 2012, p. 1592). Rhule (2005) points out that it is accepted that a treatment is designed to cause change and it is therefore reasonable to assume that deterioration is a possibility as well as improvement even if harmful consequences were unintended. An iatrogenic effect is differentiated to a negative effect (Weiss et al. 2005). A negative effect may still occur within a programme due to wider factors but not as a direct result of a specific intervention itself. Moos (2012) show that wider personal and environmental factors of the client can cause deterioration effects within the context of a programme of care but are not directly caused by the intervention itself.
Understanding this made sense of my experiences as a practitioner, especially in light of the critical incident with which I opened this chapter. Without a doubt, there were reasons beyond the programme we offered for why a client may not pass through the service as we hoped—but it was also possible that we could be part of the problem. Learning about iatrogenic effects highlighted the importance for me that we had an ethical responsibility as practitioners to really understand our craft and do no harm. It drove me to want to know what worked and perhaps more importantly, why? It got me asking questions as to why one client seemed to respond well within a programme and why another seemed to struggle even though they were receiving the same care? Without doubt, these questions have driven my academic career.
As my academic career developed, I conducted a PhD looking at evidence-based practice with vulnerable young people. The study was conducted with a charity that had successfully worked with vulnerable young people for many years. I was keen to explore the subtleties of practice that led to success or failure and to try and make sense practically and theoretically of why particular approaches worked or not. It was a study designed to help the kind of Service Managers that I had been, to have the opportunity to shape their programmes for maximum effect whilst minimising harm. It encouraged me to think about what we mean when we talk about evidence-based practice (EBP), how the wisdom of experienced practitioners could be a valuable source of knowledge for improving practice and how the variants in programmes might determine success or failure.
When considering the notion of EBP, I read Kazdin (2008) who argues that evidence must come from more than what is studied scientifically, and he is critical of the lack of evidence produced in practice contexts. As a practitioner who has seen the benefits of learning from the observation of others this has appeal. Those of us who work in practice are aware of the need to tailor interventions to individuals as they come with different needs, psychological states, support networks, cultural backgrounds, etc. Understanding how interventions—developed in a highly controlled setting—can adapt in practice is necessary. In this way I find myself in agreement with McCormack et al. (2002) who suggest that EBP should be based on three considerations: evidence, context and facilitation. Evidence is arrived at through research and experience, context is to do with culture and leadership, facilitation is about ensuring the right roles, and skills are in place to deliver practice (André et al. 2016).
This highlights the need for more practice focused academics like myself, to be working closely with practitioners to get greater insights into EBP. Although I am no longer a practitioner, my desire as an academic is to work with practitioners in such ways to help improve practice and expand knowledge.
One way that the active ingredients for effective practice can be discovered is through examining practice wisdom (PW). As Chu and Tsiu (2016) state:
Experienced frontline practitioners are repositories of knowledge that is highly personal and often unarticulated … conceptual tools and resources [should be provided] that allow practitioners to use their ability to make professional judgements, grasp scenarios accurately, mobilize knowledge and learn from both their successes and failures. There has never been a better opportunity for [researchers] … and frontline practitioners to work together in order to discover and create knowledge through action, to pass age-old wisdom and to make context specific knowledge generally accessible. (p. 52)
As a concept, PW has received little academic attention perhaps because it focuses on the inductive and sometimes intangible creation of knowledge which is difficult to articulate using objective scientific language (Samson 2015; Chu and Tsui 2016). Definitions vary as to what PW means but the idea of knowledge arising out of practical experience is a common feature of these definitions. Mitchell (2011) describes PW, “… as practice-based knowledge that has emerged and evolved primarily on the basis of practical experience rather than from empirical research” (p. 208). In this way, PW provides an opportunity to learn from experience.
Dewane (2006) suggests that skilled practice should bring together knowledge obtained through education and training as well as that arrived at through life experiences and belief systems. What might seem like intuitive practice has a basis in experience, reflection and learning from academic sources, colleagues, and clients. In this view, PW knowledge is gained through embodied reasoning (Chu and Tsui, 2016). Samson (2015) argues that for PW knowledge to emerge, two concepts should be considered. Firstly, there is the idea of tacit knowledge or “knowing-in-action” and secondly, the idea of evaluating the work a practitioner engages in or “reflecting-in practice” (p. 123). PW is based on both intuitive and analytical reasoning (O’Sullivan 2005) and therefore can be thought of as a process via which to arrive at new knowledge. Once PW is discovered, it should be scrutinised and understood in terms of how both theory and experience explains ‘why’ something works to ensure theoretical fidelity. This is where practice-focused academics are important. We can play a significant role in the critical analysis of PW.
As an academic I still feel like a novice but at the same time I believe I am pursuing something that I believe is important. Sometimes, I feel I don’t belong in this academic world but perhaps that is because a new kind of practice-focused academic is needed. I have no desire to be a renowned academic, I simply want to continue to ask important questions about practice and offer suggestions as to how we might work more effectively with vulnerable people. This is what excites me, and I know my background as a practitioner brings a perspective that is helpful in exploring emerging ideas in research regarding EBP and Programme Theory. I am more interested in finding ways for such knowledge to be shared and considered as widely as possible then finding my name in highly ranked journals as much as this might help the institution I work for with its contributions to the Research Excellence Framework (REF). (I realise this is important for funding but cannot pretend it particularly motivates me. Improving practice is the most important thing for me as an academic. Sharing knowledge that may prevent critical incidents in what can be life and death situations with vulnerable people should be of paramount importance and therefore making research and knowledge widely available and accessible is critical. I am not sure REF helps in this way.)
I am surprised to find myself where I am in my career, but it presents an opportunity and—although I sometimes feel I don’t belong—it is an opportunity I must embrace and am excited by future research and writing possibilities. Something I never imagined saying as a disenfranchised 16-year-old who left school feeling stupid.
André, B., Aune, A. G. and Brænd, J. A. (2016). Embedding evidence-based practice among nursing undergraduates: Results from a pilot study. Nurse Education in Practice, 18, pp. 30-35.
Bootzin, R. R. and Bailey, E. T. (2005). Understanding placebo, nocebo, and iatrogenic treatment effects. Journal of Clinical Psychology, 61(7), pp. 871-880.
Chu, W. and Tsui, M. (2008). The nature of PW in social work revisited. International Social Work, 51(1), pp. 47-125.
DeRoos, Y. S. (1990). The Development of PW through Human Problem-solving Processes. Social Service Review, 64 (2), pp. 276-287.
DiClemente, C. C., Schlundt, D., & Gemmell, L. (2004). Readiness and Stages of Change in Addiction Treatment. American Journal on Addictions, 13(2), 103-119. doi:10.1080/10550490490435777
Dewane, C. J. (2006). Use of self: A primer revisited. Clinical Social Work Journal, 34(4), pp. 543-558.
Kazdin, A. E. (2008). Evidence-based treatment and practice: New opportunities to bridge clinical research and practice, enhance the knowledge base, and improve patient care. American Psychologist, 63(3), pp. 146-159.
Klein, W. and Bloom, M. (1995). Practice Wisdom. Social Work, 40(6), pp. 799-807.
Litchfield, M. (1999). PW. Advances in Nursing Science, 22(2), pp. 62-72.
McCormack, B., Kitson, A., Harvey, G., Rycroft-Malone, J., Titchen, A. and Seers, K. (2002). Getting evidence into practice: the meaning of ‘context’. Journal of Advanced Nursing, 38(1), pp. 94-104.
Mitchell, P.F. (2011). Evidence-based practice in real-world services for young people with complex needs: New opportunities suggested by recent implementation science. Children and Youth Services Review, 33, pp.207-216.
Moos, R. H. (2012). Iatrogenic Effects of Psychosocial Interventions: Treatment, Life Context, and Personal Risk Factors. Substance Use & Misuse, 47(13/14), pp. 1592-1598.
O’Sullivan, T. (2005). Some theoretical propositions on the nature of PW. Journal of Social Work, 5(2), pp. 221-242.
Prochaska, J. O., & Velicer, W. F. (1997). The Transtheoretical Model of Health Behavior Change. American Journal of Health Promotion, 12(1), 38-48.
Rhule, D. M. (2005). Take Care to Do No Harm: Harmful Interventions for Youth Problem Behavior. Professional Psychology: Research and Practice, 36(6), pp. 618-625.
Samson, P. L. (2015). Practice Wisdom: the art and science of social work. Journal of Social Work Practice, 29(2), pp. 119-131.
Weiss, B., Caron, A., Ball, S., Tapp, J., Johnson, M. & Weisz, J. R. (2005). Iatrogenic Effects of Group Treatment for Antisocial Youths. Journal of Consulting and Clinical Psychology, 73(6), pp. 1036-1044.
- Further discussion on Practice Wisdom definitions can be found in DeRoos(1990), Litchfield (1999) and Klein and Bloom, (1995). ↵