Potential for bridge-building across the evidence divide?

For the first four days of last week, (thanks to much-appreciated support from the Centre for Medical Humanities), I and others from CMH (Mike White and Mary Robson) were immersed in the dynamic atmosphere of international purpose and mutual inspiration shared by 350 arts and health activists from over 20 nations – assembled at the Culture Health and Wellbeing conference in Bristol. This gathering was preceded by the valuable ‘Critical Mass 2’, (already reflected upon by Mike in a previous blog), at which 21 of us met to pump-prime the discussions focusing on international arts/health collaborations, and how to move forward in the international arena of arts and health practice, advocacy, research and policy. Impossible though it is to capture the sense of anticipation, excitement, debate and potential of the whole event, Mary and humbly I offer these two vignettes produced as part of a quick sketch writing activity in a workshop (run by artists’ collective ‘Tiny Monuments’ on Monday, day 1) in which we both found ourselves:

Entrance crowded with excited delegates, anticipation, and smiling, friendly faces. We’re a throng – with a purpose. Glasses ‘ching’-ing, whispers, the ruffle of paper and hands, the gentle slide from noise to quiet;  a patchwork of opportunity…

Sitting in the debating chamber on old leather seats, facing each other across the evidence divide. Speakers talk of stories versus numbers, of cultural barometers and controlled trials. But what’s the big idea? – it’s in the whispers of the future, not the shouts of the past.

While the panels, presentations and performances were astonishingly diverse, I picked up on themes running through the whole gathering; which I identify as hallmarks of a critical point in the evolution of what we might call the arts and health ‘movement’:

1)    Recognizing that a tipping point may have arrived for arts/health, in terms of momentum, and a level of consciousness of our numbers, reach, and links;

2)    Sharing the will, and understanding our potential, to drag ‘opportunity’ from the jaws of ‘crisis’;

3)    Understanding that we can and need to work more proactively on bridging language/s and communication gaps of various kinds;

4)    Demonstrating the will to move through and beyond our lingering differences, and to sense our strength and solidarity as a wider ‘movement’.

Of course this is not to deny that there were and are differences to be grappled with. The biggest of these seemed to lie in the (to me) frustrating tendency for every discussion on progress (political, academic, economic) for the arts and health sector to be laced with the (to me) regressive warning that we MUST provide proof of impact that adheres to a medically established hierarchy of evidence (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996) in order to be taken seriously. This evidence type is most obviously exemplified by the RCT, or ‘randomised controlled trial’, but extends to other experimental study designs. Here we hit against a problem, which, last week amongst a group of delegates including both academics and practitioners, became amplified.  We need to be careful, because people have different understandings of fundamental terms used liberally by everybody – especially when under pressure to prove again and again the value of arts and health work. I think that as a practitioner turned academic I have a feel for why anxiety and tensions increase in discussions of ‘evidence’ amongst mixed academic and non-academic gatherings; I’ll try to capture my concern here in case it helps any of us.

When academics talk of ‘evidence’, ‘research’, ‘evaluation’, ‘robust’, ‘rigorous’, ‘trustworthy’, ‘scientific’, and ‘data’, although not resolved in what may qualify as matching our different measures of these phenomena, the discussion is epistemological: the words have broadly agreed definitions, but we differ on how we believe truth may be fairly demonstrated using these tools. The discussion on this continues, and it is my particular view that all forms of ‘evidence’ can contribute to the complex narrative of arts and health: different games require different rules, or as we often say up here in the North, ‘it’s horses for courses!’ The problem causing friction between different academics is the dominant presumption of a natural, unequivocal hierarchy of types of ‘proof’, in which the order never shifts, and in which qualitative evidence as a concept is repeatedly thrown out with the bathwater of poor quality qualitative evidence.

However, when this discussion is aired and shared with arts practitioners, less likely to have taken part in the epistemological discussion on ‘research methodologies’, and more likely to have been pestered by funders, commissioners and arts advocacy bodies for ‘evidence of outcomes’ or ‘outputs’ from their work, the same terms become punitive weapons. Compelled by monitoring forms and systems to use the terms ‘evaluation’, ‘research’, ‘evidence’, ‘rigour’ and the others, but without fair induction into how they are being used by other sectors, arts practitioners develop their own sense of their meanings, ‘magpied’ from here and there, and coloured by the pressure they feel to prove their own effectiveness or lose their funding. The anxiety this creates around the language of ‘evidence’ makes arts practitioners vulnerable within the debate. The effect is a very black and white landscape in which it is very difficult for arts practitioners to perceive nuance with any confidence. How can they feel comfortable asserting that a qualitative approach is the most appropriate methodology for evaluating or researching their work, when there is so little non-academically directed guidance in how to distinguish between good and poor quality qualitative processes?

In this climate, a vagueness surrounding criteria for ensuring a good standard in qualitative methods, and the apparently high cost of qualitative processes (when seen as an ‘add-on’ that takes resources away from core activity), leads many arts organisations to become understandably depressed and resentful, and resigned to the belief that they have no alternative but to prove their work using measures that are an unnatural fit. After all, isn’t the supremacy of ‘scientific rigour’ a message that is repeatedly broadcast like a call to payer from the towers of established influence?

Most arts organisations and arts practitioners seem unaware that they have natural allies amongst health researchers (cf the journal ‘Qualitative Health Research’ or QHR, http://qhr.sagepub.com), many of whom are increasingly vocal in asserting the validity of rich, qualitative research approaches – even approaches involving creativity and arts-based processes in their interface with research participants. Perhaps there could be more organised dialogue and sharing of ideas between such health researchers and arts and health practitioners, to acknowledge their considerable common ground, and common cause?

Sackett, D., Rosenberg, W., Gray, J., Haynes, R., & Richardson, W. (1996). Evidence based medicine: What it is and what it isn’t. British Medical Journal, 312, 71-72.