The Narrative Nature of Clinical Reasoning

“…reasoning and creative thinking in consultation with the patient (and often their family) to make professional judgments and decisions on the most appropriate solutions for the patient (Rogers 1983; Mattingly 1991a, 1991b; Unsworth 2005; Higgs et al. 2008; May et al. 2008; Rassafiani et al. 2009).”

“…Occupational Therapv Foundation Clinical Reasoning Studv analyzed many aspects of therarists' thinking throughout the occupational therapy process (Crepeau, 1991; Fleming, 1991b; Mattingly, 1991), little attention has been given to therarists' thinking about the central concept of activity.”

“According to Mattingly (1991) narrative discourse frequently is used by occupational therapists when discussing clinical cases with colleagues.”

“…observed between Erin and Mira, as they stood together next to Rachel in her isolette attempting to wake her, they engaged in a type of storytelling (Clark, 1993; DeGrace, 2003; Mattingly, 1994) in which Rachel was cast as a little daughter who was beginning to respond to her mother’s voice.”

“Data were analysed both thematically for trends among the participants as well as nonparadigmatically in order to gain access to individual stories within the broader context (Mattingly, 1991; Mattingly & Garro, 2000; Polkinghorne, 1995).”

“It also involves the therapist considering the client in the context of the client’s past, present and future life and reflecting on himself or herself within the therapy process (Fleming 1991, Mattingly 1991).”

“(p. 421) More specifically, in the book Clinical Reasoning , Mattingly (1994) stated: We took seriously a part of practice that therapists generally did not notice—their own everyday storytelling.”

“Mattingly (1991) suggests narrative reasoning is a primary mode of clinical reasoning in occupational therapy.”

“Mattingly (1991) and many others have directed much of their research into developing a narrative-based therapeu tic understanding of client care that emphasizes a phe nomenological approach.”

“…narrative is shaped and purposed in medical settings (see Ainsworth-Vaughn, 1998; Atkinson, 1995; Bosk, 1992; Byrne and Long, 1976; Hunter, 1991; Mattingly, 1991; 1998; Mischler, 1984; D. Silverman, 1987) including conversation analytic studies into patient-doctor communication (e.g. Heritage…”

“…flow of papers and studies describing the types, development, use, and mastery of clinical reasoning (Cohn, 1989; DePoy, 1990; Rogers & Holm, 1991; Mattingly, 1991; Fleming, 1991b; Slater & Cohn, 1991; Schwartz, 1991; Burke and DePoy, 1991; Schell & Cervero, 1993) as well as teaching of clinical…”

“In contrast, cultural-historical activity theory incorporates the notion of appropriation, a process in which the individual is drawn into social practices and simultaneously develops new ways of thinking (49).”

“Research in clinical reasoning suggests that narrative data may be important for understanding the life story of clients (Clark, 1993; Mattingly, 1991; Schwartz, 1991), and may be helpful in determining mutually agreed upon goals for clients.”

“These included difficulties bending to pick up objects from the floor safely and difficulty rising from sitting to standing abilities with the goal to maximize overall self-care independence, appreciating “person-task-environment” perspectives (Holm, Rogers & Stone, 1998; Mattingly, 1994; Mattingly & Fleming, 1994b).”

“More recently, the clinical reasoning studies supported by the American Occupational Therapy Foundation (Mattingly & Gillette, 1991; Mattingly, 1991; Fleming, 1991) plus work by myself and others (Frank, Huecker, Segal, Forwell, & Bagatell, 1991; Hasselkus, 1989, 1991a; Hinojosa & Anderson, 1991;…”

“Mattingly [20] explained that the use of narrative, story-telling, is one way in which occupational therapists gain an understanding of a particular case.”

“Contemporary occupational therapy philosophers are encouraging therapists to understand what disability means in the context of the individual's life (Crepeau 1991; Mattingly, 1991).”

“Narratives can be useful for a variety of reasons, most notably, to make sense of experience by reflecting upon the motivations, desires, conflicts, as well as any process of change that may have been undertaken by the storyteller (Mattingly, 1991, 1998).”

“She also asserted that thinking of the client’s life as a narrative could help therapists understand a client better (Mattingly, 1991).”

“By leaving the treating therapist to take responsibility for the overall treatment, the informant did not engage in the 'double vision' Mattingly (1994a) referred to since the 'problem of the person' belonged to the other therapist.”

“The story telling, narrative approach identified by Mattingly (1991) and Mattingly and Fleming (1994) in their study of the clinical reasoning of occupational therapists, and developed by Clark (1993), Price-Lackey and Cashman (1996), and Jackson (1998) as a means of relating occupational science…”

“The ability of the parents to be able to undertake ‘chart talk’ (Mattingly, 1991) communicate in a way that conveyed a sense of speaking the same language as providers seemed to elevate their requests and insights from those of ‘just’ being a parent, to a more informed position.”

“Ofs' clinical reasoning processes have received much attention in the recent literature, and the therapist's application of occupational therapy practice models has been identified as one aspect of this multifaceted process (Barris, 1987; Fleming, 1991; Mattingly, 1991; Rogers & Holm, 1991).”

“Mattingly (1991a) described clinical reasoning as an active and complex process that combines clinical experience, tacit understanding, treatment context and client capabilities, perspectives and meaning into clinical decision making.”

“When therapists construct their clients’ stories in their minds, “this picturing process gives them a basis for organizing tasks” (Mattingly, 1994, p. 240).”

“…Bruner (1986), thinking takes form in two fundamentally different ways: paradigmatic thinking, which is expressed by logical arguments, and narrative thinking, which happens when people strive to understand, explain, and create coherence between incidents and experiences (Mattingly, 1991).”

“vism recognized in several studies (Bodner 1986; Greenfield, 2015b; Liu and Matthews 2005; Mattingly 1991; Piaget 1977; Popkewitz 1998).”

“Narrative reasoning deals with the client's occupational story, as reflected in his or her activity preferences, and focuses on the process of change needed to reach an imagined fu ture (Clark, 1993; Mattingly, 1991).”

“In FLow. In the original study of general occupational therapy practice, certain stories within the Craft dimension described a deeper level of skill in multiple contexts accompanied by an orchestration of a complex series of interventions. We likened these experiences to Csikszentmihalyi's (1988) concept of flow wher…”

“20,21 Everything we perceive is pattern-mapped into our many schemata and, as we become more experienced, we develop highly specific schemata that enable interpretation – when we are less experienced we use less refined schemata.”

“Mattingly (1991) appears to be speaking of collaborative practice when she discusses the concept of narrative reasoning.”

“While still limited in its use in occupational therapy, autoethnography fits well with the profession’s valuing of narrative reasoning (Mattingly, 1994; Schell, 2003).”

“, 2004; Jensen, Gwyer, Shepard, and Hack, 2000); osteopathy (Thomson, Petty, and Moore, 2014); nursing (Benner, Tanner, and Chesla, 1992); and occupational therapy (Fleming, 1991a, 1991b; Mattingly, 1991; Unsworth, 2001).”

“…the target person in occupational therapy needs to take action, to do, and not just to think about what s/he wants or needs to do, because what is meaningful is actively constructed and can change what s/he thinks about her/himself and what s/he wants - as Mattingly (1991) had already introduced.”

“As Mattingly suggested (9,10), clinical reasoning becomes narrative reasoning in which the biomedical discourse concerning the disease (i.”

“Although the ending of Edward’s story is uncertain, he minimized that uncertainty, demonstrating the motivation and action that are key features of emplotment and required to move his story forward and arrive "…where one longs to be" (Mattingly, 1994, p. 253).”

“Mattingly would assert that the coconstruction of a future story is central to this process.[13] Co-construction is the mechanism to build mutual respect, trust, shared knowledge, and collaboration.”

“Such research and thinking regarding the narrative form has also become of interest to occupational therapists, particularly in terms of its role in the clinical reasoning process utilized by clinicians (Mattingly, 1991).”

“…importance of establishing rapport and communicating with clients is emphasized in the literature since a good relationship between the occupational therapist and the client has been identified as a factor that will influence the effectiveness of treatment (Fleming, 1991a; Mattingly, 1991a).”

“The occupational therapist elicited Maria’s perceptions of her son’s strengths and challenges, engaging her through the process of interactive and narrative clinical reasoning (Mattingly, 1991).”

“Several authors have argued that factors such as meaning and motivation are narratively structured and constantly being created in an interactive manner, rather than being traits internal to the individual (Bruner, 1986; Kielhofner, 1995; Mattingly, 1991).”

“The presence of an “ other ” to dialogue with offers a sense of validation for an autoethnogra-pher, as they story and re-story their narrative as a part of their everyday experiences (Anderson, 2014; Mattingly, 1991).”

“Alongside my embedded occupational therapy skills, my work is influenced by the biopsychosocial approach (Engel, 1980), narrative reasoning (Mattingly, 1991), and cognitive behaviour therapy principles (Beck, 1993; Cox, 2000).”

“…is a diverse and plural concept with a complex relation to understandings of health (Fortune and Kennedy ‐ Jones 2014) but occupational therapy offers some ways to manage complicated health issues through its established core of narrative understanding and reasoning (Mattingly 1991a;1991b).”

“…narrative (storytelling) is an essential tool for client reporting (Greenhalgh, 2016), that formulation is associated with enhanced professional reasoning (Parkinson et al., 2011), and that narrative reasoning has long been considered central to the occupational therapy process (Mattingly, 1991).”

“In their efforts to engage clients in the therapy process, Mattingly (1991) proposed that therapists use a phenomenological or interpretive approach to understanding how clients privately compose their experience of disease or disability and what brings meaning to their lives.”

“…a growing interest in understanding the narratives of persons with disabilities (Helfrich, Kielhofner, & Mattingly, 1994; Jonsson, Josephsson, & Kielhofner, 2000; Mattingly, 1991) and in using nar-ratively oriented assessments (Mallinson, Kielhofner, & Mattingly, 1996) to better understand clients.”

“…the development of interviewing skills and a therapeutic use of self and self-awareness; a working knowledge of projective theories; observational and interpretive skills in the analysis of expressive activity performance, and an emphasis on narrative reasoning skills (Mattingly, 1991, 1998b).”

“The OTSs employed narrative reasoning (Mattingly, 1991; Mattingly & Flemming, 1994: Schell, 2003) while confidentially discussing cases during lunch in the office.”

“These reflections and strategies are dialectical or integrated and belong to a complete set of skills involved in general clinical reasoning processes.[27,28] The latter involves understanding the patients’ illness, conscious state, awareness and/or disability experiences, and having an idea of their story, beliefs an…”

“The hope of persons with an illness or disability, however, often involves a much broader understanding of hope as a journey towards healing or recovery, trying to fi nd a positive meaning in what has happened (79 – 83).”