Where does theory fit with practise?

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

An introduction to case formulation


One definition of case formulation is ‘Case formulation aims to describe a person’s presenting problems and use theory to make explanatory inferences about causes and maintaining factors that can inform interventions’. What this means is that it is essentially a story not just to describe, but explain, how a person’s problem has developed, and how it is maintained so that treatments can be based on influencing those factors.

There are many different frameworks for case formulation, but several key elements are usually present:

  1. a description of the presenting issues;
  2. the factors that act to create vulnerability or precipitate the problems developing;
  3. factors that may not have been involved in the initial problem developing, but are helping to maintain the problems; and finally,
  4. factors that can help the person cope or act as resources.

To move beyond just describing these factors, a case formulation should describe the relationships between these various factors and the problems that are present – and should reflect not just the visible features of the problem (ie what we can see, or what the person reports that are unique to his or her situation), but also the underlying phenomena or stable, recognisable features that are present. (more…)