Interactive Reasoning in the Practice of Occupational Therapy, S. Schwartzberg, Upper Saddle River, NJ, Prentice Hall, 2000, paper, 166 pp. illustrated, $36.20.
In the Preface, the author notes that her interest in this topic began as a result of her association with Maureen Fleming and Cheryl Mattingly while at Tufts University. The book is designed to “unravel the complexity of interactive reasoning in occupational therapy.”(p. xvi) The author approached this task from the perspective that the practice of occupational therapy (OT) is comprised of theory, philosophy, and empirical data. The author structured the book to first address philosophical and theoretical ideas. As a result of a research grant, the author then interviewed occupational therapists and from those interviews identified themes and techniques that characterize interactive reasoning in OT.
The book is divided into four major sections: Interactive Reasoning Practice in OT, Practice Environments, Practice Populations, and Education and Research. The first three sections are each comprised of four chapters. The last section is a single chapter. Within each chapter, the author begins with a case study, provides an overview of the content of the chapter, details the elements of the chapter, makes a final reference to the case study, provides a summary and then ends the chapter with reflective questions, information checkpoints (a topical outline), Critical Case Questions, and a glossary of key terms. This organizational structure should be of great benefit to anyone seeking to gain knowledge of this subject matter, whether they are students or practicing professionals.
Chapter one of the first section presents philosophers and theorists that have influenced occupational therapy. The first, entitled “The Philosophy,” introduces the reader to the work of Martin Buber who is considered by the author to be the most followed thinker in OT. In this chapter, the writings and beliefs of theorists in psychology Jerome Frank, Carl Rogers, Abraham Maslow, Erik Erikson, Robert White, Sigmund Freud, and Mihaly Csikszentmihalyi, Karen Horney, Harry Stack Sullivan, Donald Winnicott, and Margaret Mahler. She then briefly introduces the work of OT theorists: Gail Fidler, Elizabeth Yerxa, Ann Mosey, Howe and Schwartzberg, Mary Reilly, and Gary Kielhofner.
The second chapter describes borrowed practice from psychodynamics to humanistic, experiential, psychotherapy and cognitive behavioral counseling. These techniques include active listening using verbal and nonverbal communication, establishing rapport, communicating with cultural sensitivity, clarifying meaning, giving and receiving information, and testing reality through validation. Chapter three describes a model of clinical reasoning drawn primarily from Fleming and Mattingly's work and from the interview research that the author conducted in preparation for writing this book. Five types of reasoning are described: narrative reasoning, procedural reasoning, interactive reasoning, pragmatic reasoning and conditional reasoning. The author also presents a brief listing of other types of strategies used in OT that have been reported in the professional literature. She then describes the themes that were the outgrowth of her research with practicing therapists. These include active participation and collaboration, engaging and creating a holding environment, exploring and interpreting motives and occupation-based meanings, listening and finally understanding and use of narrative symbols. Each of these themes is described within the chapter with examples given either from the case study or using the words of those interviewed. The author also identifies five techniques that characterize OT practice in all settings and with all populations: selling, giving back, engaging the mood, validating and holding. Each of these is a technique of interpersonal interaction and is described with reference to the case example or using the language of those interviewed.
Section II of the book is organized around the settings in which occupational therapists practice. Chapter four describes the institutional setting including large and small acute care hospitals as well as rehabilitation facilities. The medical model is described in terms of disparity of power, laws and rights of consent, disclosure, and contracts. The challenges of this environment are described as is the role of the therapist in helping clients have a meaningful hospital experience. After describing the institutional environment, the author describes the techniques of OT (presented in chapter three) in the context of the institutional environment and presented in the words of therapists who were interviewed.
Chapter five presents OT in the school environment. In this chapter, the author specifically demonstrates the use of developmental theory in the providing of OT. In the section on active participation and collaboration, the manner in which children are empowered by providing choices is described. There is a description of client-centered interaction that involves a physical therapist with the occupational therapist and a child. Problem solving as a theme in the school setting is highlighted as the challenge of working with children with behavioral problems is described in the words of one therapist. The process of engaging and connecting with the child describes the variety of roles a therapist may have to assume to meet the child's needs. The chapter also includes sections on providing a safe environment, focusing on the child, focusing on fun, what to do when treatment does not work, and building trust with children. The chapter also includes sections on exploring and interpreting children's motives as well as occupation-based meanings, listening and understanding and using narratives and symbols. This chapter's reflective questions include specific questions related to cultural sensitivity.
The final chapter in this major section focuses on community-based OT. Each of the five techniques is again addressed this time against the backdrop of a young man who sustained a head injury as a result of a motorcycle accident. The community-based therapist particularly experiences the use of narratives and symbols and what is termed “the felt sense.” Experienced therapists are described as being more likely to trust and act on the felt sense than are novice therapists.
The third major section of the book presents lifespan issues beginning with a discussion of children and their families, middle-aged adults, friends, families and partners, and finally older adults and their caregivers.
Chapter seven, focused on children, presents the case of a 16-year-old girl with anorexia. The chapter begins with a discussion of understanding the family culture of the child; the family system is a major theme. Connection with the family and child is discussed again in the context of adapting behaviors to engage the family or child. The topics of family dynamics, family play, parental development and intuition are discussed in some depth. In chapter eight, the need for sensitivity to role changes is emphasized, and the process of “pulling one's life together” by regaining control. The importance of family is stressed as is listening skills that enable the therapist to read cues, particularly nonverbal cues. Finally, a section entitled “lighting the spark” addresses the need to motivate individuals. In chapter nine, the need to provide support to caregivers is emphasized.
The final section of the book stresses that therapeutic relationship skills can be taught. The author describes the experience at Tufts University as the model for this process. In describing the education of occupational therapists the author discusses, clinical reasoning, developing narrative reasoning ability, personal knowledge and stress management, problem based learning, multicultural sensitivity, and experiential learning. The author also presents models of research on clinical reasoning. Included in this review of research is work on the narrative process, the context of practice, and collaborating with the client. The author concludes the chapter with a question regarding the phenomenon of interactive reasoning, asking if it is a distinct form of reasoning or if it is part of clinical reasoning. That question remains to be answered.
Although it is quite true that this book is designed for occupational therapists and OT students, there is some information of interest to physical therapists. First, the presentation of theorists who have influenced the profession was both interesting and informative. For all of us who work with occupational therapists, this would provide greater understanding of their professional roots. The book also provides a good deal of insight into interactions with children and their families. The challenges of different practice settings were particularly interesting and will ring true to pediatric physical therapists. The information on providing therapy in a school setting is just as valuable to physical therapists as it is to occupational therapists, although the interventions that we provide are quite different. Likewise the information on families presented in the chapter on children would be of interest to therapists. Although I would not recommend that all those in a clinical setting purchase this book, I would suggest that libraries that provide materials for both occupational and physical therapists purchase this text, and I would encourage physical therapists to borrow the book and read the sections of interest. It will provide useful information.