T

he primary purpose of the American Occupational

The Therapist With the Therapy Association/American Occupational Ther­
apy Foundation Clinical Reasoning Study was to
Three-Track Mind identify the reasoning strategy that occupational thera­
pists used to gUide their practice. The designers of this
study assumed that there was one reasoning style that is
Maureen Hayes Fleming typical of clinical reasoning in occupational therapy. They
decided that ethnography was the research method (Gil­
lette & Mattingly, 1987) most likely to enable them to
Key Words: problem solving identify this typical or best reasoning style. However, as
investigators, Mattingly and I soon realized that tl:}.e occu­
pational therapists in the study employed a variety of
reasoning strategies. During the early stages of the re­
This article reports some of the results of the American
search project, when we were still searching for a single
Occupational Therapy Association/American Occupa­
reasoning style, the apparent use of several forms of rea­
tional Therapy Foundation Clinical Reasoning Study
Therapists are thought to use three different types of soning led us to believe that the therapists' thinking was
reasoning when solving problems in day-to-day prac­ inconsistent or scattered. Further analysis of the video­
tice. Procedural reasoning guides the therapist in tapes of treatment sessions, interviews, and group discus­
thinking about the patient's physical performance sions with the therapist-subjects gave us deeper insight
problems. Interactive reasoning is used when the into their reasoning processes. They employed different
therapist wants to understand the patient as a person. modes of thinking for different purposes or in response
Conditional reasoning is used to integrate the other to particular features of the clinical problem. The occupa­
two types of reasoning as well as to project an imag­ tional therapists in the study seemed to use at least four
ined future condition or situation for the person. Ex­ different types of reasoning: narrative reasoning (Mat­
perienced occupational therapists seem to shift
tingly, 1989, 1991), procedural reasoning, interactive rea­
smoothly from one mode of thinking to another in or­
soning, and conditional reasoning (Fleming, 1989). These
der to analyze, interpret, and resolve various types of
clinical problems. last three types of reasoning are discussed in the present
article.
Another insight was that each type of reasoning
seemed to be employed to address different aspects of
the whole problem. Eventually, we realized that the
therapist-subjects attended to the patient at three levels:
(a) the physical ailment, (b) the patient as a person, and
(c) the person as a social being in the context of family,
environment, and culture. We then saw that each type of
reasoning was employed to address a particular level of
concern. The procedural reasoning strategy was used
when the therapist thought about the person's physical
ailments and what procedures were appropriate to allevi­
ate them. Interactive reasoning was used to help the
therapist interact with and understand the person better.
Conditional reasoning, a complex form of social reason­
ing, was used to help the patient in the difficult process of
reconstructing a life now permanently changed by injury
or disease.
These three reasoning strategies appeared to be dis­
tinctly different, yet the therapist-subjects seemed to
shift rapidly from one form of reasoning to another. They
changed reasoning styles as their attention was drawn
from the original concern to treat the physical ailment to
other features of the problem, such as the particular per­
Maureen Hayes Fleming, EdD, OTR, FAOTA. is Associate Professor,
son's response to the present activity. Using procedural
Department of Occupational Therapy, Graduate School of
Ans and Sciences, Tufts UniverSity-Boston School of Occupa­ reasoning, the therapist-subjects readily moved back to
tional Therapy, Medford, Massachusetts 02155. the physical problem that they had been pursuing earlier.
They analyzed different aspects of the problem simulta­
This article was acceptedJor publication june 12, 1991.
neously. They used different thinking styles without los-

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 ing track of some aspects of the problem while they tem­ minds in order to either support or negate more than
porarily shifted attention to another feature of the one possible cause of the presenting ailment. Compet­
problem. We began to think about these styles of reason­ ing hypothesis generation was also a strategy common­
ing as different operations that interacted with each other ly used by the occupational therapists. The experienced
in the therapist's mind. We referred to these operations therapists in this study typically generated two to four
as different tracks for guiding thinking. Thus, we devel­ possible hypotheses regarding the cause and nature of
oped the notion of the occupational therapist as a thera­ aspects of the person's problem. They generated sever­
pist with a three-track mind. The track analogy helped us al hypotheses about potential treatment activities as
envision how a therapist thought about the multiple and well. However, there was a tendency among the newer
diverse issues that pertained to the patient's problems therapists to seek the right answer rather than to gener­
and the therapist's ability to influence them. ate hypotheses about possibilities. When they generat­
ed hypotheses, they tended to consider only one or two
of them.
Procedural Reasoning
Elstein et al. (1978) noticed a phenomenon that they
The therapist-subjects used what we called procedural referred to as early hypothesis generation, which they
reasoning when they were thinking about the disease or interpreted as being an attempt on the part of the physi­
disability and deciding on which treatment activities (pro­ cian to define, or mentally enter, the appropriate prob­
cedures) they might employ to remediate the person's lem space, as theorized by Newell and Simon (1972).
functional performance problems. In this mode, the Newell and Simon hypothesized that abstract thinkers
therapists' dual search was for problem definition and categorized problems or phenomena in different spaces
treatment selection. In situations where problem identifi­ or areas of the possible source of the problem or avenue
cation and treatment selection were seen as the central of inquiry. A similar notion was advanced by Feinstein
task, the therapists' thinking strategies demonstrated (1973), who suggested that physicians' thinking would be
many parallels to the patterns identified by other re­ improved if they systematically searched for sources of
searchers interested in problem solving in general and the problem using a reverse hierarchical method. Using
clinical problem solving in particular (Coughlin & Patel, this method, physicians would think of what area of the
1987; Elstein, Shulman, & Sprafka, 1978; Newell & Simon, body was involved, then what system, then what organ,
1972; Rogers & Masagatani, 1982). The problem-solving then what process, until the problem space was suffi­
sequence of diagnosis, prognosis, and prescription, ciently defined and specific problems could be identified.
which is typical of physicians' reasoning, was commonly Experienced therapists seemed to quickly identify and
used. However, the words the therapists used to describe search within the appropriate problem spaces. Novice
this sequence were problem identzfication, goal setting, therapists had more difficulty with this task.
and treatment planning. It makes sense that occupational therapists who
Experienced therapists in the study used forms of work in a medical center, as did the subjects in the Clini­
reasoning similar to the problem-solving strategies identi­ cal Reasoning Study, and for whom part of their educa­
fied by many investigators who study physicians. For ex­ tion contained long hours of medical lectures, would use
ample, therapists used all three problem-solving methods a thinking style similar to that used in medical decision
described by Newell and Simon (1972) - recognition, making. That therapists frequently used these logical rea­
generation and testing, and heuristic search. They also soning styles was expected. However, it was surprising
displayed characteristics identified by Elstein et al. (1978), that therapists often did not use these styles. This phe­
such as cue' identification, hypothesis generation, cue nomenon led us to search for other modes of thought
interpretation, and hypothesis evaluation. They inter­ that the therapist-subjects might be using.
preted patterns of cues, much like the ones that Coughlin In discussions with the therapists, a few persistent
and Patel (1987) identified among physicians and medical themes emerged. At first, these themes did not seem to
students. The structural features of the hypotheses gen­ be explicitly linked to clinical reasoning. Some seemed to
erated by the therapists were similar to those of medical be distractions from discussing reasoning. Later, we
students in a study by Allal (as cited by Elstein et aI., 1978), found that these seeming distractions were important to
that is, hierarchical organization, competing formula­ the therapists' thinking about clinical problems. Our mis­
tions, multiple subspaces, and functional relationships. understanding of these possible distractions was a result
One characteristic of reasoning common to all of the of our initial failure to recognize that therapists viewed
physicians and medical studems in the studies by Elstein clinical problems from more than one perspective. After
et al. (1978) was generation and evaluation of competing examining these perspectives, we achieved a greater un­
hypotheses. Physicians always looked for more than one derstanding of how therapists think in general and how
potential cause of the problem presented. They devoted a they think differently about different aspects of the pa­
considerable portion of their reasoning efforts to seeking tient's situation.
additional cues and rearranging hypotheses in their We were able to identify these perspectives by ana-

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 Iyzing several of the persistent themes that flowed functional limitation. Still other therapists were undecid­
through the therapists' conversations. One such theme ed about their stance on these issues.
was that the therapist-subjects often questioned what A related issue came up weeks later in a discussion
aspects of the person and the disability were appropriate group with experienced therapists. Their concern was to
for them to treat. In one group discussion, we were ana­ identify exactly what constitutes treatment. They wanted
lyzing a videotape in which a therapist was attempting to to define which of the therapist's actions were part of the
encourage an outpatient to solve a problem. The person­ therapeutic process and which were not. These thera­
al care attendants he hired all quit after only a few weeks pists were generally comfortable with the notion of treat­
of working with him. The therapist was unable to con­ ing the whole patient, but they were not sure whether
vince the patient that this was a problem. He engaged in a their conversations with patients were part of the treat­
wide range of what therapists referred to as avoidance ment. Because the therapists in this particular hospital
tactics. Clearly the therapist and the patient had differing tended to see patients on a fairly long-term basis, they
points of view on this issue. A5 the problem was dis­ knew the patients as individuals quite well. There seemed
cussed, many therapists in the group interpreted it as a to be confusion regarding whether the therapist's under­
value conflict between the patient and the therapist. standing of the individual person and his or her concerns
There were at least two value conflicts here. One was the was part of therapy or simply an artifact of the therapist's
that the therapist thought it was unsafe for the patient to personality. Some therapists felt strongly that the rela­
live alone without someone to assist him in accessing the tionship with the patient was an essential element of the
bed, the tub, the toilet, or his wheelchair. The patient had therapy. Others saw it as an adjunct to therapy. Still oth­
fallen many times while attempting these moves by him­ ers saw it as not a part of therapy. Some believed that
self, and his solution was to call the fire department in his personal discussions were inappropriate.
small town and have someone come to his house and It seemed that these two related issues of what as­
pick him up. The patient viewed this as a simple solution, pects of the person an occupational therapist treats and
whereas the therapist viewed it as poor judgment and what actions of the occupational therapist constitute the
irresponsibility. Another conflict was that the therapist therapeutic process were sources of conflict for the thera­
believed that the patient should keep himself and his pists. There were two types of conflict. The opinion held
home cleaner. The patient did not agree with this. The by some therapists that occupational therapists should
group of therapists focused on whether the therapist treat the whole person conflicted with the opinion that
should have pursued the discussion. The concern was therapists should treat only the physical problems. An­
whether or not the therapist, who specialized in treating other conflict was that some therapists were uncertain
physical disabilities, should have been discussing person­ about which of these two points of view or perspectives
al issues with the patient. Some group members believed was the right one. This conflict seemed to be created, at
that discussions of personal issues were under the aegis least in part, by a perceived conflict between the medical
of psychiatric therapists only. A therapist who worked in a model perspective and the humanistic perspective.
psychiatric setting then said that in her hospital, occupa­ Therapists who had strong beliefs that their relation­
tional therapists were not supposed to discuss personal ship with patients was an effective pan of therapy
issues; only psychiatrists were to discuss personal issues. thought that those beliefs were in conflict with the per­
In her setting, therapists could only discuss observable spective of the medical setting. Issues such as what con­
behaviors and relate them back to possible implications stitutes therapy, the role of the therapist, turf boundaries,
for such concerns as how one behaves at work. The dis­ and the necessity for scientific evidence as a validation of
cussion became more intense regarding the role of the practice all served to deny or devalue the importance of
different types of occupational therapists and what they therapists' concerns for the patient as a person. This
could and could not do or discuss with their patients. It feeling was so pervasive that some therapists had difficul­
was clear that the group members had different opinions ty appreciating the depth and compleXity of their prac­
regarding the appropriate depth and range of their inter­ tice. They seemed confused and wondered whether they
action with patients. This difference was not divided should accept their own interpretations of their practice
along specialty lines. One therapist said, "Well, I work in or the interpretations of individuals and groups around
physical disabilities and I talk about all sorts of things with them. The discussions were full of comments like the
my patients." Others confirmed her position. The thera­ following:
pists were not in agreement regarding their role in dis­
cussing the more personal issues and what they consid­ Well, J know I was supposed to be teaching the lady bathing
techniques. After all, that's my job-that's what I get paid for. But
ered to be intimate or embarrassing aspects of the she rcall\' wanted to talk to me about her grandchild. So I did and
person's thoughts, feelings, bodily functions, or history. she felt 'better and we understood each Other beller. Besides,
Some believed that therapists should treat the whole per­ what was I going to say' "Don't talk to me while you take a bath")
She has been much better at learning the bathing since that
son. However, others believed that their role was to treat session, by the way. Of course, I put on the chart, "bathing train­
only the physical aspects of the person's disability or ing," but I son of felt guilty even though I know 1 did the right

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 lhing, I know I wasn'l wasting lime chalting, bUI il could have made during the data-gathering stage, Some have exam-
looked that way,
ined different aspects of interactive reasoning, The depth
The therapists believed that the physicians, adminis- of these analyses is impressive, as is the complexity of the
trators, and especially the insurance companies did not interactive reasoning strategies discovered, A compila-
value their interactions with patients, They further be- tion of those analyses shows us that therapists appeared
lieved that these various authorities would criticize them to employ interactive reasoning for at least eight reasons
for interacting with patients and taking time away from or purposes, as follows:
what the authorities considered the real treatment, It
1. To engage the person in the treatment session
soon became clear that those therapists who valued their
(Mattingly, 1989, identified six such strategies),
relationship with the patient persisted in interacting with
2, To know the person as a person (Cohn, 1989),
them as people regardless of the requirements of the
3, To understand a disability from the patient's
hospital and reimbursement agencies, Therapists talked
point of view (Mattingly, 1989),
to, listened to, understood, and were respected by their
4, To finely match the treatment goals and strategies
patients, Therapists and patients valued these interac-
to this patient with this disability and this experi-
tions, Most therapists valued interacting with patients but
ence, Therapists call this process individualizing
did not report talking with patients, treatment (Fleming, 1989),
This process of conducting essentially two types of
5, To communicate a sense of acceptance, trust, or
practice, one focused on the procedural treatment of the
hope to the patient (Langthaler, 1990),
person's physical body and the other focused on the
6. To use humor to relieve tension (Siegler, 1987),
phenomenological person as an individual, is discussed
7. To construct a shared language of actions and
in this issue by Mattingly (1991), The point here is that meanings (Crepeau, 1991),
while two practices were conducted, only one was report-
8, To determine if the treatment session is going
ed - the procedural practice, The interactive practice, well (Fleming, 1990),
which was the unreported practice, we called the under-
ground practice. Later, we saw that although often under- It seems that although the therapists did not initially
ground, this sort of practice was important both to pa- recognize interaction and interactive reasoning as central
tients and therapists, It also had a logic or reasoning to their practice, they used it at least as an adjunct to
strategy of its own and a particular ways of gUiding thera- practice on many occasions for various reasons, Perhaps
pists' thoughts and actions, We called this interactive particular interactive strategies were used for particular
reasoning therapeutic reasons, Some of the reasoning styles or
strategies identified and the hypothesized reasons for
their use are similar to new concepts about reasoning that
Interactive Reasoning
have been proposed by various psychologists and philos-
Interactive reasoning took place during face-to-face en- ophers, Gardner (1985), for example, proposed that
counters between the therapist and the patient, It was the there are many useful ways to think and that hypothetical
form of reasoning that therapists employed when they deductive reasoning is not necessarily the only, or even
wanted to understand the patient as an individual. There the best, way to think. Many forms of reasoning have been
were many reasons why a therapist might want to know suggested by investigators who study how persons think
the person better. The therapist might want to know how about themselves and their experience within the cultural
the person felt about the treatment at the moment or context (Berger & Luckman, 1967; Bruner, 1986, 1990),
what the patient was like as a person, either out of sheer Many are concerned with how such elusive processes as
interest or in order to more finely tailor the treatment to values, norms (Perry, 1979), and symbolic meanings
his or her specific needs or preferences, Further, the (Koestler, 1948) are used to guide, gauge, frame, and
therapist might be interested in this patient in order to formulate thought and action (Bernstein, 1971; Dreyfus &
better understand the experience of the disability from Dreyfus, 1986; Geertz, 1983; Schon, 1983), Others exam-
the person's own point of view, This is what Kleinman ine properties of problems and relate them to particular
(1980) called the illness perspective, as contrasted with problem-solVing strategies, Some propose that features
the disease perspective, The therapists wanted to know of the problem will influence individuals and, in effect,
what the illness experience was like for a person. They direct them to select a particular problem-solVing meth-
wanted to understand the patients from their own point od, Such features may include salient characteristics of a
of view, Interactive reasoning occurred when therapists task or problem (Hammond, 1988), the context (Greeno,
took the phenomenological perspective (Kestenbaum, 1989), individual interests and talents (Gardner, 1985), or
1982), although the therapists did not typically use that experience (Dewey, 1915),
term to explain a shift to the humanistic point of view, The notion that characteristics of the presumed
Several people have been interested in the clinical problem will prompt a particular thinking process
reasoning study and have analyzed various Videotapes seemed to be borne out in our observations of the thera-

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 pists in the clinical reasoning study. The therapists shifted which is often difficult and sometimes painful or distaste-
from one form of thinking to another. They often noted ful, seems to require a considerable amount of what
subtle cues and responded to them rapidly, then re- Gardner (1985) referred to as interpersonal intelligence.
turned to another task and thinking mode without "skip- Gardner postulated two kinds of interpersonal intelli-
ping a bear," as one observer commented. gence: "The capaCity to access one's own feeling life" and
If such numerous reasoning strategies exist, and if the "ability to notice and make distinctions among other
the therapists had different purposes in mind for using individuals in particular among their moods, tempera-
interaction as a therapeutic medium, then it also seems ments, motivations and intentions" (p. 239). Interactive
likely that the purpose of the interaction would prompt reasoning requires active judgment (Buchler, 1955) on
the use of a particular reasoning strategy. For example, in several levels simultaneously. This requires that the
trying to understand the person as a person, therapists' therapist analyze cues from the patient, transmit his or
reasoning resembled what Belenky, Clinchy, Goldberger, her interpretation of the patient, and interpret the pa-
and Tarule (1986) described as connected knowing, tient'S interpretations of the therapist's interpretations
which they linked to empathy. In trying to understand the qUickly and accurately. This reciprocal process is one that
disability from the patient's pOint of view, therapists used Erikson (1968) considered essential to identity formation
a phenomenological approach similar to that advocated and future social interaction capabilities. Possibly, the
by Paget (1988). Therapists' interactions with patients therapist's ability to interact successfully and therapeuti-
created an understanding of the person as an individual cally is strongly linked to his or her personal and profes-
within a culturally constructed point of view, or what sional identity. Gardner hypothesized that interpersonal
Schutz (1975) called a reciprocity of motives. intelligence is based on a well-developed sense of self.
When individualizing treatment, therapists appeared Certainly it is linked to professional self-confidence. Nov-
to be functioning intuitively rather than analytically. Ham- ice therapists reported that in their first year of practice
mond (1988) proposed, however, that intuitive reasoning they did not have the confidence, nor did they believe
is as effective and complex as analytical reasoning. Intu- they had the right, to interact with patients as individuals.
itive reasoning is employed in response to problems that They reported that they "stuck to the procedural" until
are not well defined. Tasks in which there are many cues they were confident in their use of those skills. We ob-
from several sources and that require perceptual rather served therapists even in the second year of practice
than instrumental measurement, Hammond argued, in- going back and forth between the procedural and interac-
duce the person to use intuitive methods of problem tive modes of treating their patients. In the experienced
solving. He further asserted that in these situations, ana- senior therapists, procedural and interactive forms
lytical reasoning would be less effective than intuitive seemed to flow together, each enhancing the other.
reasoning. We therefore found that interaction, which at first
The interactive reasoning strategies that Mattingly seemed like a distraction from treatment or, at best, an
(1989) identified indicate that therapists use several ways adjunct to it, was a necessary and legitimate form of ther-
to engage the patient in treatment. To be effective, some apy. Interactive reasoning was used effectively by most
of these strategies require complex interpretations of therapists to gUide this aspect of their treatment. It ap-
subtle interactive cues. The 23 interactive strategies that pears that procedural reasoning gUides treatment and
one therapist used in treatment, which were identified by interactive reasoning guides therapy. Although interac-
Langthaler (1990), seem to suggest that the therapist was tive reasoning is far less easy to map than procedural
partially influenced by psychoanalytic theorists such as reasoning, we will continue to make observations and
Rogers (1961) and occupational therapy theorists such as develop theory in this area.
Fidler and Fidler (1963) and Mosey (1970). This finding is
not surprising, because occupational therapy students
Conditional Reasoning
are required to read the works of these theorists. The
complexity, subtlety, and facility with which some thera- The concept of condi tional reasoning is perhaps the most
pists used numerous interaction forms, however, suggest elusive notion in our proposed theory of a three-track
processes far more complex than could be accounted for mind. Yet we are firmly, if intUitively, convinced that there
by professional education alone. is a third form of reasoning that many therapists used.
We also had a strong sense that the therapists' rea- This reasoning style moves beyond specific concerns
soning about and interaction with patients was directly about the person and the physical problems placed on
related to their values. Their sense of the importance of them to broader social and temporal contexts. The term
patients as individuals leads one to draw parallels to be- conditional was used in three different ways. First, the
liefs about ethical and moral decision making, such as therapist thought about the whole condition, which in-
those expressed by Gilligan (1982), Kegan (1982), and volved the person, the illness, the meanings the illness
Perry (1979). The task of monitoring the patient's feelings had for the person, the family, and the social and physical
about the treatment and yet managing that treatment, contexts in which the person lived. Second, the therapist

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 needed to imagine how the condition could change. The when he is 5 [years oldl and maybe going 10 school. I think of
imagined new state was a conditional (i.e., temporary) what I can do [Q help him develop lhe skills thaI he will need [Q
function in school and in the community and whal he will be like
state that might or might not be achieved. Third, the and how his family will be wilh him.
success or failure of treatment was contingent on the
patient's partiCipation. The patient must participate not Here Cathy describes a process of imagining and integrat­
only in the therapeutic activities themselves, but also in ing images of the past, present, and future for this child
the construction of the image of the possible outcome, given the variables of the child himself, his developmental
that is, the revised condition. delays and disabilities, his family situation, the social and
Conditional reasoning seems to be a multidimen­ educational opportunities available to him, what he
sional process involving complicated, but not strictly logi­ might be able to do in the future, and how she might
cal, forms of thinking. In using conditional reasoning, the enable that future condition to come about.
therapist appears to reflect on the success or failure of the Clearly, it takes professional experience to be able to
clinical encounter from both the procedural and interac­ project the possible developmental pattern and potential
tive standpoints and attempts to integrate the two. Think­ rate of success in attaining a future developmental Jevel. It
ing then moves beyond those immediate concerns to a also requires a mind that is imaginative, curious, and
deeper level of interpretation of the whole problem. The interested in future pOSSibilities. Conditional reasoning
therapist interprets the meaning of therapy in the context involves a way of thinking that may include a systems
of a possible future for the person. The therapist imag­ perspective and that extends to the future (Mattingly,
ines what that future would be like. This imagined future 1989), yet it moves beyond this perspective to an analysis
is a guide to bringing about a revised condition through of present interactions (Kielhofner, 1978; Mattingly,
therapy. This thinking process is essentially imagination 1989), so that one can envision how these interactions
tempered by clinical experience and expertise. might help create a better life for the child.
The therapists tried to imagine what the person was Having constructed these images, which changed
like before the injury. Similarly, they tried to estimate or slightly over time and throughout the course of treat­
imagine what the possibilities were for the person's fu­ ment, the therapists used images as a way of interpreting
ture life. By imagining, therapists mentally placed the the importance of the patient's treatment. Therapists
person in contexts of current, past, and future social would mentally compare the patient's abilities today and
worlds. The therapists used imagination in order to best the relative success of today's treatment session against
match the treatment selections to the specific interests, images of what the person was like before. They also
capacities, and goals of the person. Thus, the therapists compared where the patient was today to where they
were able to make their current treatment relevant to the wanted the patient to be in the future. Each therapist
individual patient. The present treatment, therefore, was would envision the patient today and estimate how close
not simply a link to future performance, but also, was that was to where he or she thought the patient should be
imagined within the context of a life in process. at this pOint in the course of treatment. They would men­
Perhaps this form of reasoning is best described by tally check to see how far the patient had come toward
example. Cathy, a pediatric therapist, was the most articu­ attaining the future the therapist had in mind. The evalua­
late about using this form of reasoning. Cathy usually tion of today's treatment was made in the context of past
treated very young children who lived in the community and future possibilities. Therefore, the particular state of
and had come to an outpatient early intervention pro­ things today would serve as a mental mile marker for
gram. The child's mother or guardian was usually pres­ indicating progress toward a distant, and perhaps only
ent, and Cathy invariably included the mother in the ses­ dimly perceived, future.
sion. The mother might be enlisted to hold the baby in an One reason that we called this conditional reasoning
advantageous position or to help sustain the child's inter­ was because a change in the present condition was condi­
est. Cathy would often talk to the mother while simulta­ tional on the therapist's and the patient's participation in
neously working with the child. She often asked ques­ effective therapy. This condition was dependent not only
tions like, "Does he do this at home l " "Does he usually cry on the therapist's ability to engage the patient in treat­
in this sort of situation?" "What does he like to do?" "Does ment in the sense discussed in the interactive section, but
he usually have difficulty calming himself down?" These also on bUilding a shared image of the person's future
were not diagnostic history-taking questions in the medi­ self. This image bUilding was often accomplished through
cal procedural sense. Cathy said she asked these ques­ stories or narrative, as described by Mattingly (1991).
tions to construct an image of what the child was really However, in many aspects of therapeutic interaction, the
like on a day-to-day basis. She told us that she used this images that the therapists helped to build were often
image to structure her treatment and imagine possible based in action. Pediatric therapists often included the
goals for the child. As she said, mother in creating a mental image of the child in the
I see lhis lillIe child and his movement pauerns and his difTicul­ future. This image was projected into the distant future,
lies, and then I imagine what he will be like in 2 years and then such as when a therapist wondered what an infant she

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 was treating would be like in school several years later. the whole person, therapists mean that they treat the
Therapists projected images into the near future as well. person as a whole, not as the sum of ill and healthy parts.
They also used images as a way of extending therapy into The phrase putting it all together seemed to mean
the home setting. Cathy said to the child's mother, that although the therapists often had to think only about
"Would he do this at home? Could he just sit quietly and the disability or only of the individual patient at a given
look at something and have this nice position? Could the moment, they were concerned that they eventually
kids maybe hold him like I am doing while they watch thought and did something about the patient as a whole
TV?" Here she created a visual image, based on action in person, that is, person, illness, and condition. Although
the present, of the child in a near-future situation. This they used several types of reasoning and addressed sever­
was done not only to enhance the therapy, but also to al different types of concerns, therapists always wanted
build an image of the child as a participant in the family, their reasoning to track back to making a better life for
rather than just as a disabled baby. the patient as a person. Their ultimate goal was to use as
One technique for conveying these images that many strategies as necessary to improve the individual
therapists often used was to tell patients that they were functional performance of the person. Because functional
getting better and to produce evidence of this by saying performance reqUires intentionality, physical action, and
such things as, "Remember when you could not do this? social meaning, it is not surprising that persons who con­
Now you can." Sometimes the therapists would also use cern themselves with enabling function would have to
this technique for themselves. Therapists commented address problems of the person's sense of self and future,
that when they were discouraged with a patient's pro­ the physical body, and meanings and social and cultural
gress, they found it helpful to remind themselves of how contexts - contexts in which actions are taken and mean­
far the patient had come. This technique helped both the ings are made. Because these areas of inquiry are typically
patient and the therapist focus on the importance of their guided by different types of thinking, it seems necessary
joint participation in this enterprise of treatment. It that therapists become facile in thinking about different
helped them through difficult, frustrating, and boring aspects of human beings using various styles of reason­
times and allowed them to place the moment in a more ing. Perhaps these multiple ways of thinking guide the
positive, though abstract and distant, context. Most im­ therapists in accomplishing and evaluating the mysteri­
portantly, it seemed to remind them that the condition ous process of "putting it all together" for the person.
was changing. Such changes were often quantitative, such This process, which enables the whole person to function
as increased range of motion, and would be noted in the as a new self in the future, seemed to be gUided by a
person's chart. But qualitative changes and their mean­ complex yet unidentified form of reasoning that was both
ings were equally important to therapists and patients. directed and conditional.
Although these changes were not reported in the pa­
tient's chart, they did indicate progress toward that
Conclusion
shared future image that the therapist and patient jointly
constructed and worked toward. Meaningful progress The Clinical Reasoning Study showed that therapists use
was best measured through the therapist's and patient's several different types of reasoning to solve problems and
collective memory. Therapists were not simply saying, to design and conduct therapeutic processes. Further,
"This is progress. Remember how bad things were be­ the particular reasoning processes are selected to gUide
fore?" Instead, they were saying, "If you have come this inquiry into different aspects of the person's problem or
far, maybe we will get to where you imagined you would of the therapist's intervention. As part of this research
be, even though you are discouraged today." process, we developed a theory about these reasoning
processes and constructed concepts to which we added
terminology in order to discuss these concepts among
Putting It All Together: Treating the Whole
ourselves and with the therapists. Thus, we referred to
Person
the type of reasoning that was used to gUide those as­
The therapists in the Clinical Reasoning Study often used pects of practice that are concerned with the treatment of
two phrases to describe their treatment -putting it all the patient's physical ailment as procedural reasoning.
together and treating the whole person. Treating the interactive reasoning, we propose, is a type of reasoning
whole person did not mean that the therapists were in that therapists used to guide their interactions with the
charge of the patient's whole medical and psychological person. Conditional reasoning is both an imaginative
treatment. In fact, in the traditional medical sense of the and an integrative form of reasoning that the more profi­
word treatment, occupational therapists are peripheral cient therapists used to think about the patient and his or
to the patient's treatment. The phrase was intended to her future, given the constraints of the physical condition
convey the belief that therapists concern themselves with within the patient's personal and social context. The
the patient as a person, that is, as an individual with many therapists who were part of this study confirmed our
facets, interests, and concerns. By saying that they treat assumptions that they use different forms of reasoning

The Ame,"ican Journal oj Occupalional Therapy 1013

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cepts and terms useful in understanding and explaining of Occupational Therapy, 41, 399-400.
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ory and women's development. Cambridge, MA: Harvard Uni­
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1014 November 1991, Volume 45, Number 11

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