1. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 2 Therapists’ Assumptions as a Dimension of Professional Reasoning Barbara Hooper

2. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Thinking About Thinking “The range of what we think and do Is limited by what we fail to notice. And because we fail to notice That we fail to notice There is little we can do To change Until we notice How failing to notice Shapes our thoughts and deeds” From “Knots” by R.D. Laing

3. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins What Are Assumptions? Social representations that are “either explicitly considered…true or…followed implicitly as their truthfulness is…beyond doubt” (Valsiner, 1997, p. 23) –C&PR: Assumptions orchestrate actions in practice

4. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins A Flower Metaphor for Assumptions & Impact on Actions

5. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Evidence: Therapists’ Assumptions About Human Influence OT reasoning processes are linked to assumptions about: –Human experience –The body

6. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Assumptions: Human Experience Case study: Aware of divinity within Assumes that humans: –Use cosmic power for peace & resistance to suffering –Use evolutionary history to recover movement patterns –Are a single mind-body-soul unity –Are protected by layers; when diminished, are vulnerable to illness & disease These assumptions are how this OT understood & explained interventions (Hooper, 1997)

7. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Assumptions: Human Experience (Con’t) Qualitative study #1: Goal setting in a work program –Assumption: OT is culturally rooted in common ideas about human experiences –Informants assumed that all humans: Move forward, take steps, mark progress, & set objectives –OTs did not understand why some clients were noncompliant; questioned client motivation

8. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Assumptions Human Experience (Con’t) Qualitative Study #2: Informants unaware of how assumptions influenced: –Choice of therapeutic approaches –Explanations given when therapy was unsuccessful “Therapy is…founded on…cultural perspectives…. [Therefore] therapeutic tools…that…reinforce their own conceptions of the world [are selected].” (Kielhofner & Barrett, 1998, p. 351)

9. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Assumption: The Body Study participants acknowledge “body as machine” &/or “the lived body” –Assumption: “Body as machine” focuses on dysfunction & associated interventions –Assumption: “The lived body” can lead to engagement in living tasks Allowing reconstruction of self (Mattingly, 1994a, 1994b)

10. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Evidence: Therapists’ Assumptions About Knowledge Influence Professional Reasoning Assumptions: Knowledge acquisition & generation Assumptions: Knowledge is core to OT practice

11. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Assumption: Knowledge Acquisition & Generation Adults experience stages of assumptions Stage & associated assumptions guide student learning Research: Initial assumption – knowledge is certain –Clinical knowledge obtained from experts in situ (Baxter & Magolda, 1999; Belenky et al., 1996; Kegan, 2000; King & Kitchener, 1994)

12. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Assumption: Knowledge Acquisition & Generation (Con’t) Later stage: “Contextual knowing” & “constructed knowing” are viewed as uncertain –Knowledge is generated & obtained through social groups –Continuous remodeling or construction process Knowledge is like an improvisational comedy troupe –A new “show” emerges in response to each unique audience & venue –Immersed OTs build new “shows” in response to unique clients & practice venues

13. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Assumption: Knowledge Acquisition & Generation (Con’t) In education of OTs: Assumptions about knowledge influence actions taken

14. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Evidence: Assumptions Impact the Future The future of the client The future of the therapist An ultimate future beyond time

15. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Impact on the Future “Our therapy exists in the shadow (or the light) of the end; that is, in our hopes & images of the future & what we will be able to bring about for our patients & for ourselves.” (Hasselkus & Dickie, 1994, p. 153)

16. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins The Future of the Client Study: Therapists’ expectations were expressed for the near future –Expectation: Improvements to client’s “arm & hand” –Result: Therapists selected treatment for neuromotor recovery Persisted with this approach after recovery stalled Therapists’ expected role: A facilitator of neuromotor change (large part of recovery after CVA is spontaneous) (Hasselkus & Dickie, 1994)

17. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins The Future of the Client (Con’t) Therapists expected clients to: –Regain same occupations & return home These assumptions guided therapeutic approaches –Provided criteria for success When therapists’ expectations were thwarted, dissatisfaction resulted “Occupational therapy in stroke practice was driven by expectations” (Hasselkus & Dickie, 1994, p. 636)

18. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins The Future of the Therapist Study: OT practice tied to therapist’s own future vision –Expected outcome supported own OTs’ future image “From behind the label therapist emerges a person who hopes to make a difference & a connection…we can see acts of making within the roles of patient & therapist” (Peloquin, 1997, p. 168)

19. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins An Ultimate Future Beyond Time Each OT assumes a future beyond time Case study: –Belief: Therapy fought suffering & difficulty –Perhaps a better afterlife for client Greater peace & less strife (Hooper, 1997)

20. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins How Do Assumptions Shape Professional Reasoning? Assumptions shape what therapists see, affect the interpretation they make, & guide what course of action they select

21. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Assumptions Shape Professional Reasoning Assumptions evolve “habits of expectation” through understanding culture, experience, & language Habits provide a basis for judging, selecting, & interpreting experience Assumptions: –Filter & direct attention –Guide & constrict choices –Interpret the meaning of experience (Mezirow, 2000)

22. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Impact on Practice Therapists’ understanding their own assumptions could: –Support –Limit –Contradict clinical actions (Tornbohm, 1991)

23. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins What If Our Assumptions Are Limiting to How We Practice? “There is much evidence to support the assertion that we tend to accept & integrate experiences that comfortably fit our frame of reference & discount those that do not” (Mezirow, 1991, p. 35)

24. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Reflection on Assumptions Reflection on content – thinking about what happened Reflection on process – thinking about perceptions, thoughts, judgments, feelings, & taking action Reflection on premises – thinking about why we perceive, think, feel, or act as we do –The dynamic for transforming assumptions ( Mezirow, 1991, p. 111)