abductive reasoning

Where does theory fit with practise?


ResearchBlogging.org
When I was an undergraduate, thinking about what postgraduate study I wanted to do, I wavered between enrolling in a Science Masters, or an Arts Masters. It made absolutely no difference in terms of the papers I could study – they were the same for either degree – but it did make a difference to the end degree. I decided on science. This is despite people saying ‘but therapy is just as much an art as it is a science’! Why? Loads of reasons, but several really spring to mind:

  1. Science emphasises the importance of and reliance on empirical observations and theory
  2. Science doesn’t rely on ‘intuition’ and ‘special insights’ into people and how they tick
  3. Scientific method supplies the tools I want to use to understand and investigate treatments that work because I want to ensure the patients I see get the very best, most effective input

This belief that science is critical to patient care is supported by many commentators – quoting from the paper I mentioned yesterday, ‘evidence based practice advocates that every rehabilitation and health professional should have an interest in delivering the best possible services to his or her clients, based whenever possible on the best clinical practices available from the research evidence.’ (Chwalisz & Chan, 2008)

Where does theory fit with this?

Dunn and Elliott (2008) state ‘a theory is a collection of coherent, related ideas derived from what is already known about some phenomenon in order to explain some existing behavior or to predict the occurrence of future behavior. Any theory, then, is used to establish causality and, in effect, to explicate what sequence of events led to what particular outcome or set of results.’

They go on to say that many theories are borne of clinical observations, or from the laboratory or simply from reading other pieces of literature.  Some of these settings are far removed from the often confusing and uncontrolled environment of the ‘real world’ – a laboratory doesn’t look a lot like a group pain management programme! But both settings provide opportunities for observing empirical phenomena – regular, stable features that occur and call for explanation.

I’ve blogged before about abductive reasoning: this is reasoning from descriptions of patterns to plausible explanations…moving from an ‘effect‘ to a potential causal mechanism.  It’s these possible causal mechanisms that go on to be developed into models or theories that can then be tested.  The problem I see is that there are many semi-formed theories that are being tested, and fewer really sound descriptions of stable clinical phenomena.

Anyway, back to theory.  Dunn and Elliott list nine advantages of a good theory:

  1. simplicity – straightforward, few special assumptions (no pleas to ‘energetic forces’!)
  2. consistency with what is already known – it can break new ground, but it should also fit with other knowledge eg phantom limb should ‘fit’ with medical knowledge about tissue healing, as well as other psychological knowledge
  3. empirical integration – it can borrow from empirical information from other domains of knowledge – eg occupational therapy theory can and does borrow from psychology theory, from cognitive psychology and even computer science
  4. organising and communicating findings – theories provide frameworks for organising what we observe, it needs to be readily understood by other professionals working in a similar field
  5. the importance of being general, not overly specific in scope – fits with more than one type of health condition
  6. shared, not owned – theories are public, living ideas within communities, open to criticism, extension and revision
  7. guiding and directing subsequent research – a good theory will generate questions, these questions will add to and open up areas for further investigation
  8. being highly practical – Kurt Lewin, social psychologist, made the point that ‘an effective theory remains useful as long as it predicts and explains relevant behavior’.  A good theory generates testable questions that can lead a researcher into unexpected directions to work with practical problems.
  9. open to adjustment and change – theories are meant to be tested against other theories to find out which gives the best, broadest, simplest and most accurate explanation.  This means they will be revised frequently, and even put aside if the evidence simply doesn’t fit.

What does this mean for yours and my clinical practice?

It means we need to keep our eyes open for patterns that have not been either fully described or fully explained. This means we need to be aware of our cognitive biases (see my previous posts on this!), we need to observe with our ears, eyes and hearts open.  We need to record accurately.  And every now and then we need to step back from our daily practice to take a look at what we’re actually seeing.

If we find an interesting pattern (for example, my finding in my Masters thesis that many people with chronic pain who are seeking work are socially anxious), we need to investigate it.  Now I don’t mean leaping in with an explanation: I mean taking some time to find out more about social anxiety and people with disabilities seeking work.  Does this observation hold for all people looking for a job change? Does it hold for all people with chronic pain? Does it only hold for those who have to change careers, or does it apply to people who are changing job only?

Once we’ve got a good handle on what it is we’re looking at, then we might be ready to come up with a tentative explanation or model or theory that can generate useful hypotheses.

How does this work within clinical practice?

Hopefully all of us record our observations, take notes, use questionnaires or other measures.  Hopefully we collate these observations so we can look at grouped data in different ways: using exploratory data analysis, and hopefully we will keep our biases in mind, and see what new relationships form between the factors we observe.  Then we can start to wonder and ponder and pose interesting questions about how and why.

And then we can start to consider a model or theory and try to organise our information around it, to see how well it fits.

And at the same time, we can draw on existing theories and models (eg the biopsychosocial model) to shape our clinical practice – remembering that none of us can state, with hand on heart, that we have ‘the answer’.  Remembering too, that the theories we rely on today should be constantly questioned.  Theories that don’t fit with what we see, especially if what we see occurs regularly, probably need to be revised.  It might not be ‘the patient’ who doesn’t fit or who is an anomaly, it may well be our theory or model.  Do you and I have the courage to say ‘I don’t think I know what’s going on?’ And then carry on finding out what might be?

Dana S. Dunn, Timothy R. Elliott (2008). The place and promise of theory in rehabilitation psychology research. Rehabilitation Psychology, 53 (3), 254-267 DOI: 10.1037/a0012962

Science and therapists


I’ll admit I’ve been warped a little by psychologists. No, I haven’t learned to blame my parents for how I’ve turned out (that’s why my mother wouldn’t let me study psychology when I left school!), but psychology as a field of science has definitely made me more thoughtful and critical of how I make clinical decisions – and opened up a whole approach to therapy that I’ve adopted and integrated into my practice.

A strand of thought in clinical psychology is the ‘scientist-practitioner’ model, promulgated in the Boulder, Colorado Conference of 1949 (and argued about ever since!). This model basically proposes that clinical psychologists need to adhere to scientific methods, procedures and research in daily practice.

To quote directly from the Wikipedia entry:
Core tenets of the Scientist-Practitioner model include:

* delivering psychological assessment (Psychological testing) and psychological intervention procedures in accordance with scientifically-based protocols;
* accessing and integrating scientific findings to inform healthcare decisions;
* framing and testing hypotheses that inform healthcare decisions;
* building and maintaining effective teamwork with other healthcare professionals that supports the delivery of scientist-practitioner contributions;
* research-based training and support to other health professions in the delivery of psychological care;
* contributing to practice-based research and development to improve the quality and effectiveness of psychological aspects of health care.
(this is an excerpt from Shapiro, 2002)

How does this play out for me in my clinical practice? And how does this differ from the ‘Problem-solving Process’ I was trained in during my occupational therapy training?

The occupational therapy process involves identifying problems, finding solutions, choosing a solution, implementing the solution, reviewing the outcome. I don’t really have a problem with this except that it omits the critical parts of setting the problem in context and developing a set of competing hypotheses that are systematically tested until the best explanation for the ‘problem in context’ is found.

These two parts are the two I’ve adopted from the scientist-practitioner model. The importance of identifying who has the problem and what the problem is cannot be over-emphasised, and neither can the process of reviewing the context of the ‘problem’. Sometimes the ‘problem’ isn’t actually a problem for the client, but rather, for someone else in the healthcare team.

Let’s unpack that with an example: I was asked to review the case of a woman who had mobility problems after an accident, and who had been assessed as needing a new vehicle so she could get out in the community. The problem was framed as her need to be able to independently drive in and around her community, and the contributing factors were her limited range of movement in her legs, obesity, and pain. She couldn’t sit for longer than 10 minutes or so, but moved very slowly and heavily using a walking frame. She couldn’t rotate around her spine, and she found bending forward difficult.

She had been prescribed a new vehicle because she couldn’t get in and out of the old vehicle she had. She’d recently had a new flat area bathroom installed, had rails throughout her house, a special chair for her in the lounge, and a kitchen that was modified and had a stool for her to perch on with a higher-than-normal benchtop so she could use it from the stool.

What was the problem? The functional problem was that she had trouble getting in and out of the car.
The solution? Get a new car!
BUT then I came in and started reviewing a few things…
What were the contributing factors – although I’ve already alluded to her mobility problems, and obesity, I haven’t revealed that her main problem was low back pain that she developed several years ago when she was involved in a car crash. She has gained weight since the crash, and is now morbidly obese. She has neuropathic pain over her right lower leg, and also has very thin skin that is easily damaged as she has asthma and has been using steroids for many years.

Contextually? This woman lived alone, but had many hours of home help. She had some strong beliefs about her pain, her accident, her right to compensation, her need for support, and her need for home modifications. She had never participated in any pain management programme. She believed her pain should be ‘fixed’ and she was angry that it had not responded to surgery or other medical interventions. The case manager was irritated that this woman had received over $40,000 in assistance not including earnings compensation, and was concerned that although a new vehicle might be nice, it wasn’t entirely necessary. The case manager thought that modifying the old one would be sufficient.

Let’s put this together.
Here is a woman with a range of beliefs about her entitlement to compensation, a passive attitude to rehabilitation, a system that had provided her with modifications to her house, but had never been exposed to therapy to review how she managed her pain, how to improve her mobility, how to reduce her weight, or even how to cope with the range of emotions she experienced since her accident.

I would lay good money down and bet that every clinician who saw this woman thought they had her best interests at heart. They were solving her immediate problems, and she was entitled to what she had been prescribed. The housing modifications and recommendations for vehicle and home help were all within normal entitlements – and clinically appropriate…
BUT
and in this case it’s a VERY big BUT
Although they served to ‘solve the problem’ in the short term, they didn’t help at all in the long term.
Sadly, by providing this woman with ways to avoid confronting her pain and learning to manage her pain effectively, and work through her thoughts, beliefs and attitudes, she had been strongly encouraged (and undoubtedly inadvertently) to remain passive in her own rehabilitation, to fear her pain, to reduce her mobility, and to remain very disabled.

So, where does the science come in?
I think one of the first things therapists need to do is review the reason for referral and be mindful of the bigger picture – in other words, the context. I think the scientific method as depicted in the hypothetico-deductive model misses out on the process of discovery which is all about looking at the bigger picture and seeking patterns.
The pattern evident in this woman’s presentation is that despite receiving all this assistance, she was not becoming any more independent. In fact, she was becoming more dependent on all the modifications and equipment she had received. This would be appropriate if she had a deteriorating condition like multiple sclerosis, but definitely NOT when it comes to chronic pain.

The clinicians also needed to review the science of pain and pain management – what are the evidence-based approaches to helping people become independent with pain management? Equipment prescription and housing modification receive very limited support in the literature.

Clinicians also need to review their basic science – how are behaviours maintained? How do we encourage change? What do we know about how people learn? Reviewing this would have meant this woman might not have had her requests for more and more help reinforced by receiving help.
And it might have been useful for therapists involved with her care to review the long-term effects of providing equipment – OK for short-term needs, not OK for long-term health maintenance.

A problem for many therapists is the lack of critical thinking – why was this referral made? Who has the problem? What alternative hypotheses could be considered to help her?

Being client-centred does not mean being client-directed. This woman would not have identified that she wanted to manage her pain better – she simply wanted it gone, and she wanted a new car so she could go out and about. What no-one seemed to have asked was how she was going to get around the places she drove to!

Being really client-centred would have involved working with her to review all the factors in her presentation, and recommending an evidence-based intervention: good cognitive behavioural therapy for pain management, gradual reactivation, therapy to help her manage her distress and anger over her condition, and possibly even a move to accepting pain instead of resenting it.

Science is about systematically observing and questioning everything – building on current knowledge and context, and coming up with new hypotheses for testing until finally a ‘useful explanation’ is arrived at – ready for the next, deeper discovery that can provide an even more ‘useful explanation’.
‘Useful explanations’ are not necessarily ‘true’ – they are just helpful, explain the majority of the presentation we see, help make predictions about the future, and make the least number of assumptions. The problem with the previous therapists approach for this lady was that they used an outmoded explanation that didn’t fit with the context of her presentation, and didn’t account for many of the contributing factors.

And that’s why I’ve adopted the scientist-practitioner model – because it continually asks the questions: Why? What’s going on here? How come? What would happen next?

For some more readings about science, I’ve really enjoyed the following:

Renewing the Scientist Practitioner Model D. Shapiro, 2002

Bob Dick’s unpublished paper discusses whether it’s time to review the model

Terry Halwes paper on Truth in Science – and the section about Western Science whcih is about 2/3 down the home page

And finally, a book I’m enjoying on ACT, or Acceptance and Commitment Therapy, for anxiety – but equally applicable for pain:
New Harbinger Publications produces a range of science-based self help books. I looked on my desk and I have four sitting there without me even looking! The Mindfulness & Acceptance Workbook for Anxiety is the latest one I’m enjoying. I started by looking for a relatively simple book on how to introduce mindfulness and acceptance to people experiencing pain. I already have the Living Beyond your Pain ACT book, but it doesn’t quite hit the spot for my clients. So I’m hoping to take extracts from both to develop something helpful for the people I work with – something a little less wordy and abstract. Not easy, but that’s me!!

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See you again soon…

Clinical reasoning – more than problem solving…


Once upon a time, I was a baby occupational therapist, newly graduated, and I dutifully followed what I had learned as ‘the occupational therapy problem solving process’.  This process was:

  1. Identifying the problems (usually as identified by ‘the client’ who was often the person I ended up seeing, but just as easily could be the person who had referred the person I saw…) – this involved assessment
  2. Identifying the potential solutions (being creative, and based on clinical knowledge of ‘what works’ and included biomechanics, psychosocial factors, developmental stage and the end result that was being aimed for)
  3. Choosing a solution (that could be whatever was most pragmatic, least expensive, quick to implement, suited the client, or I had learned was ‘a good solution’)
  4. Implementing a solution (just getting on and ‘doing it’ – but it might involve selective grading of complexity of the activity or task or equipment or environment)
  5. Reviewing the satisfactoriness of the solution (often through ‘reassessment’, but even more often through asking ‘did it work?’)
  6. If it didn’t work, repeating the process…

What I developed through my undergraduate education was a working knowledge of anatomy, physiology, psychology (particularly developmental stages, cognition, and behaviourism), sociology (especially roles within society and responses to social environments), pathologies of various types – and the gift of learning about the value of ‘being active’ or engaged in ‘occupation’ or ‘valued activities’.  I can’t recall the exact wording, or even references now (it was HOW many years ago?!!), and I do remember graduating thinking ‘I’m not really sure what makes occupational therapy ‘different’ from other professionals, but I think it’s something to do with activity and of course, we do learn about how groups work’.

Very quickly I became quite disenchanted with occupational therapy – and quite abruptly had to face some hard facts about what I learned, and the way other professions (and this thing called ‘science’) worked.  And it was this: that problem solving process which I had hammered into me misses the point.  In fact, because of the way many occupational therapists practiced then (and I have to say, practice even now…), the profession suffered from the accusation that it couldn’t respond to – ‘jumping in with solutions before really knowing the problem’.  

Ouch!

I’ve pondered this for ages…why is it that occupational therapists, who are well-meaning, often very well educated, and have such laudable aims for their therapy, why do they ‘jump in’ with solutions so quickly?

Some of the thoughts I’ve had about this include:

– client-centred can mean that because of lack of insight by the client, contributory problems that underlie the problems the client identifies don’t get brought to light

– there is no specific step to specifically examine, through hypothesis generation, a number of competing explanations for the problem arising

– because of information processing heuristics, clinical reasoning can be shot by human characteristics common to all professions:

– the tendency to identify a pattern out of random data when it might actually be random

– the tendency to remember unusual or unique factors more readily than the familiar

– the effect of recency and primacy (information that is new or recently learned, information that comes first or is over-learned)

–  information provided/required by an ‘important’ team member is recalled quickly

– our difficulty setting aside a preliminary conclusion, along with our ability to seek confirmation that our hunches are correct (rather than waiting for more information before deciding on an option, and difficulty actively seeking disconfirmatory evidence)

– that we don’t recognise the context of the situation – why, who, what are defining ‘the problems’ – some ‘problems’ may be problematic for one party, but pretty good for another

– theory, and especially theory from other domains of information apart from ‘occupational science’ – such as neuroanatomical, cognitive, behavioural, family systems, attachment theory, biomechanics – I could go on!! need to be systematically reviewed in relation to how they might contribute to ‘the occupational performance problem’ – and this is an incredibly complex assessment model!

– the biomedical model continues to dominate and individual’s needs are ‘diagnosed’ often in terms of ‘deficits’ rather than interactions between an individual with values making daily choices of behaviours and that individuals’ environment

I’m drawing quite heavily on the abductive process in clinical reasoning now – what that means is that I have steeped myself in a number of models that appear to be relevant to pain and pain management.  One of the most prominent models is the cognitive behavioural model.  As a result, while I’m ‘assessing’ a person (translate this to ‘having a conversation with the person so I can begin to understand their situation’), I’m actively looking for patterns in their presentation.  Although they may describe their ‘problems’ at the same time I’m looking for both the good things and the not so good things about what they construe as a ‘problem’.  AND I’m looking at the various cognitive and behavioural (oh and biophysical) things that are potential explanations for the initiation and maintenance of their situation.  I’m actively seeking disconfirmatory evidence throughout the ‘assessment’ process for any hypotheses that I generate during the first contact – so, if they mention difficulty sleeping, feeling tearful, lacking energy – I’m also looking for information that might refute one of my initial assumptions that ‘they’re depressed’ – what else might explain their presentation?

Effectively, I’m broadening out the range of potential explanations that I’ll later need to systematically review.  I’m also eliminating things that I might initially think of as a ‘pattern’ but later I find to be a one-off, or unique event.

As a result of this, I look at both the client and what he or she identifies as ‘problems’, but at the same time attempting to look at strengths, possible explanations, and areas that can be explored in more detail.  This means a significantly increased emphasis on assessment (or, as I prefer to put it, learning to understand their situation).

It’s only once some explanations have been developed that possible options for changing the presentation can be identified.  Otherwise I (and the client) can risk prematurely applying a ‘solution’ that:

  1. doesn’t solve the problem, because it’s focusing on the ‘wrong’ mechanism
  2. creates other problems, because the interaction between that ‘solution’ and the rest of the system hasn’t been considered
  3. prevents uncovering deeper concerns that are maintaining (through inadvertent benefits) the situation

Well, that was a bit of a philosophical ponder!! I hope you followed it – and that you’ll think about dropping me a line to let me know what you think.