Clinical Reasoning In

Psychosocial Occupational Therapy:

The Evaluation Process

Roann Barris

This qualitative study attempted to exploreand describe the

initial evaluation process in psychosocial occupational
therapy. Obseruation of19 therapists interoieuiingpatients,
detailed transcriptsofthoseinteroieus, interuieuis with the
therapists, and two questionnaires on therapists' beliefs and
attitudesaboutpsychosocial occupational therapy and men-
tal illness were analyzed. Resultssuggested that the initial
evaluation interuieui process variesin termsofcontent and
format; links exist between interviewformats and types of
treatment programs; communication of therapist beliefs
seems to be an importantfacet oftheinteroieui, as with other
healthprofessionals, much routinization seems to exist in
clinical decision making; and the environment appears to
be a more peruasiue influence on clinical reasoning than
personal beliefs and attitudes.

Roann Barris, EdD, OTR, FAOTA, was Assistant Professor, OCcupational

Therapy Program, University of Wisconsin-Madison, at the time of this
study.
Key Words: clinical judgment. decision making • treatment planning
148 BARRIS

Clinical reasoning is a relatively elusive process; until recently, it had

not been the subject of much research in either occupational therapy
or other professions. It is elusive because it is an ongoing, interactive
process of decision making, involving art, science, and ethics (Rogers,
1983), and because it is private-individuals rarely voice the steps they
follow during decision making.
Yet, clinical reasoning (or clinical decision making) is an integral part
of practice in fields where design or problem solving is involved. Schon
(1983) referred to it as a process of reflecting-in-action and suggested
that, ideally, it should not be approached as problem solving but as prob-
lem setting. In other words, every time a practitioner faces a new client
or situation, he or she must find a frame that allows the client to be
viewed as unique. Problem setting thus leads to a process of defining
goals and means interactively with particular reference to each client or
frame. The extent to which this is done, however, is questionable.
The purpose of this investigation was to explore the early stages of
clinical reasoning-the initial interview or assessment-used by occupa-
tional therapists in psychosocial practice. The study proceeded from the
formulation of four basic questions: What happens during the initial oc-
cupational therapy psychosocial interview? Are there observable trends
or patterns that characterize this stage of clinical reasoning? How does
the clinical reasoning of psychosocial occupational therapists compare
with that of other health practitioners? What factors, if any, appear to
influence the clinical reasoning of occupational therapists in psychosocial
practice?

REVIEW OF LITERATURE
The most extensive studies of clinical reasoning have involved physi-
cians; however, a few studies in health-related fields and in education
also exist. These studies consistently point to a tendency for decision-
making or reasoning processes to become increasingly routinized and
decreasingly interactive over time (Broderick & Ammentorp, 1979;
Clavelle & Turner, 1980; Watts, 1985). When interactive decision mak-
ing does take place, it is more likely to involve fine-tuning of an already
selected strategy or deletion of something that was planned than a deci-
sion to incorporate new strategies (Clark & Yinger, 1977; McNair,
1978-79; Rogers & Masagatani, 1982).
Another commonality of clinical reasoning that has been observed is
a tendency to generate a limited number of hypotheses about the pa-
tient (Elsteinet al., 1978; Payton, 1985) and, concomitantly, to disregard
or not use information that may not fit into the original hypotheses
 THE OCCUPATIONAL THERAPY JOURNAL OF RESEARCH 7:3 149

(Elstein et al., 1978; Rogers & Masagatani, 1982; Watts, 1985). Politser
(1981) suggested that this may occur because the clinician does not want
to give up early hypotheses or may simply not notice or remember
relevant but dissonant information.
Indirect and direct investigations of clinical reasoning have found that
it is influenced by a variety of factors: knowledge, personal values, situa-
tional or environmental features, and length of experience (Barris, 1984a;
Baumann & Bourbonnais, 1982; Cohen, Weinberger, Mazzucca, &
McDonald, 1982; Kielhofner & Nelson, 1983; Knafl & Burkett, 1975).
Taken together, research findings point to interaction among all these
factors in determining the process of clinical reasoning. Thus, when clini-
cians are uncertain as to the outcome of their methods, they may become
overly reliant on a particular "school" of professional work and its con-
comitant techniques (Freidson, 1970; Light, 1980). At the same time, they
may place increasing emphasis on the value of clinical experience and
become wary of new book or classroom knowledge. The final result may
be a static process of clinical decision making and treatment planning.

METHODOLOGY
A variety of approaches have been used to study clinical reasoning, each
with its own merits and shortcomings. Because of its nature, the pro-
cess of clinical reasoning is largely invisible. Any attempt to examine
it, even under the most realistic conditions, introduces an element of
reflectiveness and self-consciousness that may not normally be present.
Methods range from naturalistic approaches such as in vivo study and
high-fidelity simulations to paper-and-pencil tasks and interviews
(Elstein et al., 1978). The format used in this study reflects an attempt
to be unobtrusive to both therapists and patients while taking place in
the natural environment. It combined observations recorded as a written
transcript, a brief interview with the observed therapist, a request for
therapist feedback on the written transcript, and the completion of two
paper-and-pencil attitude scales by the therapist.

Sample
The study consisted of observations of occupational therapists work-
ing in mental health settings. Therapists who participated had at least
two years of experience, had supervised either level-one or level-two
fieldwork students, and were still engaged in direct patient contact.
Therapists who were interested in participating and who met the criteria
also needed to be able to arrange an evaluation/interview with a recently
150 BARRIS

admitted patient. The therapist was asked to ascertain whether the pa-
tient was willing to have an observer present during the evaluation and
to assure the patient that his or her responses were not going to be the
focus of the observation. The 19 therapists who participated worked
in Madison, Wisconsin; Dallas, Texas; New York City; Detroit, Michigan;
and Providence, Rhode Island.
The completed observations took place in day and inpatient programs.
The settings included psychiatric wards in general hospitals, private
psychiatric hospitals, long-term care facilities, and community mental
health centers. Participating therapists had from 2 to 17 years of ex-
perience; 4 had entry-level master's degrees in occupational therapy, one
had an advanced professional occupational therapy degree, and the rest
had baccalaureate degrees in occupational therapy.
Procedure
Five experienced occupational therapists, currently enrolled in either
advanced professional occupational therapy master's degree programs
or in doctoral programs in related fields, served as data collectors for
the study. These therapists were asked to arrange observations of three
to five occupational therapists in psychosocial practice living in their
geographic area. Observations were to be made of each therapist con-
ducting an initial or early interview with one client.
Data collectors were given a set of written instructions and a sample
transcript recorded by the author. The instructions included suggested
interview questions and a format for obtaining information. Each data
collector received feedback from the author as to the completeness of
the obtained information, and all were able to provide further infor-
mation when necessary.
Observers were directed to explain to the therapist that they were
interested in the treatment-planning/decision-making process used by
occupational therapists. During the observation, they were to write
down as much as possible of what the therapist said and only enough
of the patient's response to put the therapist's comments or questions
in context. After the patient interview, the observer interviewed the
therapist to obtain a description of the treatment program, role of oc-
cupational therapy in the setting, types of treatment groups offered,
usual sequence of events with new admissions, and any other pertinent
information. Observers were also instructed to question the therapist
about any events during the patient interview that may have been puz-
zling to them.
Following the interview, the observers typed up their transcripts and
sent them to the therapists, along with two attitude questionnaires.
 THE OCCUPATIONAL THERAPY JOURNAL OF RESEARCH 7:3 151

Therapists were asked to note any comments they might have had on
the transcripts, their intents during the interview, anything they might
have done differently, or their feelings about what they did do. In ad-
dition, they were asked to complete the two questionnaires and then
return the transcript and questionnaires to the observer. Data were col-
lected in this way over a period of eight months.
The Psychosocial Beliefs Questionnaire (PBQ) is a refinement of a
questionnaire used in a study of psychosocial occupational therapy
ideology (Barris, 1984a). It addresses beliefs about the role and func-
tions of the occupational therapist in psychosocial settings and consists
of three subscales corresponding to neurophysiological beliefs, occupa-
tional behavior beliefs, and psychodynamic beliefs. Item/subscale total
correlations found that most items had positive moderate correlations
with the expected subscale and little or negative correlations with the
other two subscales (Barris, 1984b).
The second questionnaire, the Client Attitude Questionnaire (CAQ)
(Nevid & Morrison, 1976), is a 20-item measure of the degree to which
a person holds a medical model or more radical psychosocial model
perspective on mental illness. It has been shown to be highly reliable
and to have construct and discriminative validity (Morrison & Becker,
1975; Morrison & Hanson, 1978; Morrison & Teta, 1977).
Data Analysis
Data analysisbegan with a general reading of all transcripts. Next, recur-
ring content areas in therapists' questions and the types of questions
or comments used were identified. An ongoing record of these ques-
tions and themes led to a list of 67 types of statements that appeared
at least once in a transcript. These categories were rather specific; for
example, asking about goals, asking about plans, and asking how the
patient thought occupational therapy could be helpful were included
as separate categories.
After this list was compiled, the transcripts were reviewed again. Each
statement was coded in terms of the master list; if appropriate, a state-
ment was given more than one code. Thus, a follow-up question about
work history would be coded as both asking for elaboration and focus-
ing on the content area of work.
Information from the observers' interviews with the therapists was
also recorded. Information of interest related to therapist review (or
non-review) of medical records before seeing the patient, types of goals
set for the patient, and other treatment program data.
Finally, the two questionnaires were scored. Of special interest here
was the identification of therapists who had extreme scores. The
152 BARRIS

transcripts of therapists who varied greatly from the means on these

instruments were compared to determine whether their interviews
might show the influence of their extreme scores.

RESULTS
Although some of the data were quantified during the process of ex-
amination, data analysis in this study was far more individualized and
interpretive than in quantitative research. Therefore, the following
discussion represents the researcher's speculations about the initial in-
terview and early clinical decision making in psychosocial occupational
therapy.
Four themes will be used to organize the discussion: the variability
of content in interviews; communication of the therapist's beliefs or
paradigm to the patient; influences on the therapist's clinical reason-
ing; and comparisons with occupational therapists working in the area
of physical dysfunction.

Variability in the Initial Interview

The substance of the interview varied greatly. Some therapists had a
heavy focus on leisure, asking the patient about past and current in-
terests, whereas others were more concerned with process skills and
patients' perceptions of their ability to concentrate, cope, and so on.
Another type of interview relied heavily on questions about work
history and behavior. Out of 67 possible types of statements or ques-
tions that appeared in the interviews, 13 were used for approximately
half of all the coded statements. Of these 13, the most frequently used
types of statements were supportive comments or positive feedback
to the patient (used 46 times; appeared at least once in all but two in-
terviews) and probing questions, i.e., asking the patient to elaborate
on something already said or to provide an example or explanation (also
used 46 times, although 6 interviews had no statements coded for this
category). This form of probing was not necessarily used to obtain more
detailed information but often was an attempt to help a patient make
an abstract or vague response more concrete. For example, in the
following excerpt, a patient had marked the interval between 2:00 and
5:00 p.m. on a time-use inventory as "sick";
Therapist (T): What does sick mean to you?
Patient (P): Pain.
T: Can you describe what you mean by pain and sickness?
P: ... It was put on me.
 THE OCCUPATIONAL THERAPY JOURNAL OF RESEARCH 7:3 153

T: I'm unclear when you say, "That was put on me .... "
P: [Goes on to describe parents getting on his back about work and other aspects of
his life]

Other frequently used statements included explanations of occupational

therapy (appeared 25 times), discussions of how occupational therapy
would help the patient work on his or her problems or goals (30 times),
and questions asking for the patient's goals (35 times). In addition, ques-
tions about leisure (30), home life (33), work (62), finances (21), family
(29), self-care or personal management (23), symbolism used by the pa-
tient in an expressive activity (32), and the patient's current emotional
state (25) were frequently asked. However, 6 therapists had no questions
related to work, 7 asked nothing about leisure, 10 asked nothing about
daily time use, and 10 did not include questions about activities of daily
living.
Types of statements that appeared only once in any of the interviews
were those asking about the patient's best and worst periods in his or
her life, asking the patient whether a particular type of problem situa-
tion might occur in occupational therapy, responding to a personal ques-
tion asked by the patient, and asking about the patient's response or reac-
tions to the interview.
Although most of the therapists appeared to use an interview developed
at their setting, a few used existing interview formats. The Occupational
History was the basis for three interviews; one therapist used the Adoles-
cent Role Assessment; and another incorporated a mental status exam
and perceptual-motor screening test into the interview.
Discussion. These interviews leave one with the impression of a great
degree of variability in terms of actual content foci. Explanations of the
assessment process and of occupational therapy appeared to be central
to many ofthe interviews, possibly to set the patient at ease and to pro-
vide an overall framework for the encounter. Such a framework may
have been necessary, in part because the interviews often took place in
open, undefined, trafficked areas and in part because patients may not
know what to expect from occupational therapy.
Despite the amount of variability, it was possible to hypothesize cer-
tain patterns of connections between evaluations and treatment programs
from these observations. One pattern consisted of a highly structured
and focused evaluation combined with a program that emphasized a par-
ticular area of treatment, such as vocational development or commu-
nity living skills. In this pattern, the interview, which often emphasized
either a detailed work history or a thorough investigation of time use,
seemed to have been developed in response to long-term observations
154 BARRIS

of patient problem areas and to reflect a particular theoretical emphasis

in the program.
The second pattern consisted of an evaluation that frequently emanated
from an activity completed prior to the interview, usually a collage. The
interview then focused on psychodynamic issues: an exploration of the
symbolism used by the patient in the collage, a discussion of family
dynamics, or a focus on the patient's feelings and intrapersonal ex-
periences. These interviews tended to address only minimally content
areas such as work or leisure. They were used in settings that had
psychodynamically oriented programs, and their purpose seemed to be
to develop rapport and to establish the therapist as a supportive in-
dividual. In these settings, occupational therapy appeared to be used as
one of several strategies for helping the patient achieve general
psychodynamic goals, as illustrated by the following therapist's goals:
... use humor but be sensitive to what it mightmean to the patient; model a more relaxed
appearance, low-key affect, and comfortable way of interaction; pay attention to his need
to be in a helping role . . . .

In the third pattern, the interview seemed to be an attempt to gather

general information about many areas of the person's life. Sometimes
these interviews also proceeded from the completion of a written ques-
tionnaire by the patient, after which the therapist reviewed responses
to the questions with the patient. Sometimes a goal checklist the patient
was asked to complete was used as either the sole or partial basis for
the interview. The purpose of these interviews seemed to be one of the
following: to obtain information for the team to use perhaps in discharge
planning, to identify areas where in-depth assessmentmight be necessary,
to establish rapport with the patient, or to arrive at certain conceptualiza-
tions as to the type of performance that could be expected from a pa-
tient and how better to work with that patient.
This interview type seemed to be prevalent in settings that empha-
sized the development of task skills and self-esteem in their programs.
In some of these settings, the program was based on levels of cognitive
behavior and the interview was partially used to place the patient into
the appropriate level group. More commonly, however, the program of
groups was the same for all patients, and it was not completely clear
how the interview information led to treatment program decisions (an
observation also made by one of the data collectors), either because all
patients were referred to the same groups or because decisions about
groups were based on other criteria such as age, the unit the patient was
on, or the doctor's referral. These settings often appeared to be a hybrid
of psychodynamic and cognitive approaches, as well as more traditional
arts and crafts.
 THE OCCUPATIONAL THERAPY JOURNAL OF RESEARCH 7:3 155

An impression that emerges from these programs is one of therapists

who are unclear as to how they can maintain their occupational therapy
identity and heritage within the constraints of the mental health system.
These therapists appeared to be caught between some of their theoret-
ically based beliefs and the changing treatment environment. For
example, one of the data collectors commented that, in her department,
therapists gathered information related to occupational behavior but were
unable to incorporate it into a short-term treatment program. Asa result,
the connection between the evaluation and the actual treatment program
seemed tenuous.

Communication of the Therapist's Beliefs to the Patient

Interviews, although often used to establish rapport, were not a parallel
interaction for therapists and patients. In general, therapists clearly
maintained control of the direction of the interview. They rarely
answered questions (only 6 instances were recorded), and when they
did, answers tended to be nondirective or not explicit. Therapists main-
tained their control by predominantly asking questions, by choosing
a focus that sometimes deviated from a focus the patient seemed to be
choosing, by occasionally disregarding a patient comment that may have
been deemed tangential or irrelevant, by hypothesizing to the patient
about the cause or context of a particular problem, or by using a sup-
portive comment. Goal setting also appeared to be a means of
establishing control. Ultimately, interviewer control seemed to be im-
portant in that it provided an opportunity for the therapist to com-
municate his or her beliefs about occupational therapy to the patient.
Discussion. The initial interview may be the beginning of a process
in which the therapist is consciously or otherwise trying to convince
the patient to accept his or her view of what the patient's problems
are and how they have been affecting or will affect the patient's life.
Therefore, the therapist may focus on only those issues that fit with
his or her framework or may reshape or redirect the patient's statements
so that they begin to fit. For example, in the following excerpt the
therapist wants to communicate to the patient a psychodynamic way
of looking at problems.
T: What kind of feeling would you describe to interpret the center picture? (Picture
is captioned with large letters: STRESSFUL.)
P: I have co-workers who look like that .... I hate my work, days are really bleak
.... [Patient talks in great detail about the stress and injustice of his job and relates job
as being the cause of many physical as well as mental problems.)
T: That word stress relates to you ... it relates to your illness [italics added).
156 BARRIS

What is noteworthy is that the patient began talking about work and
stress in a concrete, functional way; the therapist, however, wanted to
pursue the psychodynamics of stress and continued this psychodynamic
focus throughout the interview. In another example, the therapist wanted
to explore the family dynamics but the patient did not:
T: Did the separation have anything to do with the way you are now? Where is the
marriage right now? Do you think you'll get back together?
P: [T has paused between questions, but P has made little response.)
T: Who asked for the separation?
P: I don't want to talk about it right now.
T: That's okay.
[Nurse brings in medications and patient asks a question about dosage.)
T: That's good to know and care about what you are taking; that's good. [T then changes
the topic to a discussion of how the patient's depression has been affecting her at work.)

The therapist finally changes direction only after an interruption, which

seems to allow her to save face. However, later when the therapist writes
up her treatment plan for the patient, she includes further exploration
of family issues as her first goal.
Goal setting also communicated the therapist's paradigm to the pa-
tient. Patients were often encouraged to choose their goals from a preex-
isting list or to word their goals in terms that matched the type of treat-
ment program available. Because goal setting was structured in this way,
certain goals became acceptable or feasible, whereas others would be
discarded. Ultimately, goal setting appeared to be an important way of
asking the patient to accept the therapist's dominant role, as well as ask-
ing the patient to accept the therapist's explanation of how occupational
therapy would be helpful.

Influences on Clinical Reasoning

Therapists' scores on the PBQ and on the CAQdid not reveal a consis-
tent relationship to their interview format or their approach to treat-
ment. For example, two therapists had very high scores on the
psychodynamic subscale of the PBQ and appeared to have a very
psychodynamically oriented program. However, some therapists whose
scores on this scale were substantially lower also had strong
psychodynamic programs. Similarly,whereas one therapist who scored
high on the occupational behavior subscale as well as on the CAQ (in-
dicating rejection of a medical model view of mental illness) had a pro-
gram that emphasized community living skills and work behaviors,
another therapist with a high occupational behavior score had a pro-
gram that was based on principles of management of cognitive
 THE OCCUPATIONAL THERAPY JOURNAL OF RESEARCH 7:3 157

disabilities. Conversely, a therapist with a very low score on the oc-

cupational behavior subscale had a program that emphasized work, ac-
tivities of daily living, and constructive use of time.
If beliefs and attitudes have an equivocal effect on evaluations and
treatment, then what does influence therapists' clinical decisions? In
some cases, the patient population appeared to be an important factor.
For example, therapists interviewing patients with histories of substance
abuse tended to be more confrontive than other therapists, to focus on
work and time use, and to try to engage the patient in identifying situa-
tions in which work or daily life was being impaired by the substance
abuse. A therapist who worked with psychogeriatric patients relied
largely on a mental status assessment during his interview and stated
that a major purpose of the occupational therapy assessmentwas to con-
tribute to the differential diagnosis of the patient in ruling out dementia.
Probably the hospital setting was another major influence. In short-
term settings, therapists who obtained detailed occupational-history in-
formation said they did not know how to incorporate this information
into their program, given the time frame they had. A therapist who used
principles of rational emotive therapy in her program worked in a
hospital where this was the basis for the psychiatry department.
Tradition within the occupational therapy department also con-
tributed to the therapist's approach. Although some of the therapists
in this study worked alone, none was a department head; as expected,
they used the approach to interviewing and assessment that had already
been established within the department.

Comparisons with Physical Dysfunction Occupational

Therapists
There are some interesting similaritiesand differences between this sam-
ple of psychosocial occupational therapists and the therapists working
in physical dysfunction who were studied by Rogers and Masagatani
(1982). One of the most striking differences concerned the use of
medical records. Rogers and Masagatani observed that therapists in their
study usually obtained information from the medical chart before see-
ing the patient; this information was, in fact, often the basis for their
choice of assessment. Only two of the therapists in the present study,
however, stated that they reviewed medical records before meeting the
patient. Seven therapists were adamant about not wanting to read
medical records first; they expressed the belief that such prior
knowledge might prejudice them toward a certain preconception of
the patient or cause them to focus on a problem area that had already
158 BARRIS

been identified rather than following their own intuition and inferences
about possible problems.
Routinization of treatment was an area in which the psychosocial
therapists were similar to those in physical dysfunction and to other
health professionals. Almost all the programs relied on either one assess-
ment or a combination of two or three that were used with all patients.
Therapists did not choose their assessments or interview format; it was
already established for the occupational therapy department as a whole.
In at least five settings, patient goals were also standardized, selected
from a preexisting goal checklist.
Further, treatment programs were routinized as well, as patients were
frequently assignedto all the groups. For example, one therapist described
an assertiveness group to a patient and explained that she tried to get
everyone in that group because almost everyone could benefit in some
way. Other therapists stated that they felt most goals could be worked
on within the context of most groups, so someone without work-related
problems might still be assigned to a work group but would concentrate
on interpersonal or self-esteem related goals.
Occupational therapists in psychosocial practice seemed to do more
probing than physical dysfunction therapists (although this may reflect
a verbal as opposed to a performance-based approach). Rogers and
Masagatani (1982) commented that therapists in their study often used
just one marker to ascertain the patient's performance in a particular area
(for example, putting on a shirt as an assessment of dressing ability). The
psychosocial therapists were likely to ask many questions related to a
given area of behavior and to encourage patients to explore in pro-
gressively more detail an area of their lives.
As in the physical dysfunction evaluations, therapists stated that they
do not often deviate from their planned assessment format. The reasons
given for deviation generally related to patient limitations, such as
cognitive dysfunction or reading problems, or to patient behavior, that
is, a patient who is actively psychotic or too resistive. In such cases,
something was eliminated from the interview or covered in less detail.
Only rarely did therapists indicate that deviation took the form of a more
in-depth assessment. Usually when this did occur, it was related to self-
care behavior.
Discussion. These areas of differences and similarities raise interesting
points. First, the preference for approaching the patient without
background information may rest on a questionable assumption. If a pro-
gram and interview exist in a setting, then it seems unlikely that a
therapist would not have some type of plan in mind when approaching
a patient. Such a plan would operate as a filter in much the same way
 THE OCCUPATIONAL THERAPY JOURNAL OF RESEARCH 7:3 159

that reading the chart does. Even if this is not the case, a problem created
by not reading charts is the duplication of information already available
and time spent collecting information that may lie outside the domain
of occupational therapy.
The routinization of goals and treatment groups would seem to im-
pose a static framework on the identification of patient problems and
possible approaches that can be taken with patients. Although this
routinization may reflect the pressures of documentation and short-term
treatment, one is still forced to wonder whether all patients can be so
neatly defined in terms of goals and treatment strategies.
STUDY LIMITATIONS AND CONCLUSIONS
This study proved to be surprisingly more difficult to conduct than an-
ticipated. Therapists were often quite reluctant to be observed, and the
interview/observation process was time consuming. Although 5 peo-
ple served as data collectors, observations were completed on only 19
therapists. In addition, several other graduate occupational therapy
students had indicated an interest in observing therapists and then
withdrew, either because of the time commitments or because of in-
ability to arrange observations with local therapists. A more intrusive
form of data collection-use of audiotapes or videotapes, which would
have provided a great deal more information-would have been
nearly impossible to implement given the nature of psychosocial treat-
ment and the reluctance of therapists to participate in this type of
research. As a result, although this study provides a closer look at the
clinical evaluation processes used by occupational therapists in
psychosocial practice than has been obtained previously, it nevertheless
suffers from many shortcomings.
The obvious limitations include the nonrandom approach to therapist
selection and the small sample size. In addition, each therapist was ob-
served only once. It is possible that that one observation represented
a highly atypical interview for the therapist. A more serious problem,
however, concerns the incomplete explanations of events obtainable from
the therapists who were observed. The strategy used in this study did
not focus on what the therapists were thinking as they proceeded through
the evaluation. Some of the subjects did include much of this type of
information when they read over their transcripts, but others simply
looked to see if the transcript was reasonably accurate. Thus, the discus-
sion of what happened during the interviews represents only the in-
vestigator's interpretation of the events.
Given these limitations, there are several conclusions that remain to
be drawn from this study. First, in terms of clinical reasoning, occupa-
160 BARRIS

tional therapists in psychosocial practice do not appear to be that different

from their colleagues in physical disabilities or in other health-related
disciplines. The differences that do exist would seem to be situational
or environmental and not necessarily inherent in any differences among
clinician groups.
Second, apart from the necessary interaction that occurs during an in-
terview, the framework of the evaluation and treatment planning pro-
cess seems to impose a static dimension on clinical reasoning. Although
the contingencies of daily practice surely contribute to this, there must
be other reasons as well. Educators must especially ask themselves why
this seeming reluctance to adopt an interactive stance to treatment plan-
ning is so pervasive in clinical practice.
Finally, although this is the first study that has attempted to take a dose
look at part of the clinical reasoning of psychosocial occupational
therapists, it is certainly not the definitive one. Studies such as this and
the one by Rogers and Masagatani (1982) need to be replicated, expanded,
and improved upon; quite simply, there is a need to know more about
what it is that occupational therapists actually do on a day-to-day basis,
why they do it, and what they think about it.

Acknowledgments
This research was supported by a grant from the AmericanOccupational Therapy
Foundation. I would like to thank the therapists and patients who agreed to
be observed during interviews, as well as Karen Crane, Bette Bonder, Vickie
Schindler, Mary Hostetler-Brinson, and Betty Hasselkus for their invaluable
assistance with data collection.

REFERENCES
Barris, R. (1984a). Toward an image of one's own: Sources of variation
in the role of occupational therapists in psychosocial practice. Oc-
cupational Therapy Journal of Research, 4, 3-23.
Barris, R. (1984b). Response to commentary: A reply to Clark and
Sharrott. Occupational Tberapy foumal of Research, 4, 117-125.
Bauman, A., & Bourbonnais, F. (1982). Nursing decision-making in
critical care areas. Journal of Advanced Nursing, 7, 435-446.
Broderick, M. E., & Ammentorp, W. (1979). Information structures: An
analysis of nursing performance. Nursing Research, 28, 106-110.
Clark, C. M., & Yinger, R. J. (1977). Research on teacher thinking. Cur-
riculum Inquiry, 7, 279-304.
 THE OCCUPATIONAL THERAPY JOURNAL OF RESEARCH 7:3 161

Clavelle, P. R., & Turner, A. D. (1980). Clinical decision-making among

professionals and paraprofessionals. journal of Clinical Psychology,
36, 833-838.
Cohen, S. j., Weinberger, M., Mazzuca, S. A., & McDonald, C.}. (1982).
Perceived influence of different information sources on the decision-
making of internal medicine house staff and faculty. Social Sciences
and Medicine, 16, 1361-1364.
Elstein, A. S., Shulman, L. S., Sprafka, S. A., Allal, L., Gordon, M.,}ason,
H., Kagan, N., Loupe, M.)., &}ordan, R. D. (1978). Medical problem
solving: An analysis ofclinical reasoning. Cambridge, MA: Harvard
University Press.
Freidson, E. (1970). Profession of medicine: A study of the sociology
of applied knowledge. New York: Harper & Row.
Kielhofner, G., & Nelson, C. (1983). A study of patient motivation and
cooperation/participation in occupational therapy. Occupational
Therapy journal of Research, 3, 35-46.
Knafl, K., & Burkett, G. (1975). Professional socialization in a surgical
specialty: Acquiring medical judgment. Social Sciencesand Medicine,
9, 397-404.
Light, D. (1980). Becoming psychiatrists. New York: Norton.
McNair, K. (1978-79). Capturing inflight decisions: Thoughts while
teaching. Educational Research Quarterly, 3, 26-42.
Morrison,). K., & Becker, R. E. (1975). Seminar-induced change in a com-
munity psychiatric team's reported attitudes toward "mental illness."
journal of Community Psychology, 3, 281-284.
Morrison,). K., & Hanson, G. D. (1978). Clinical psychologists in the
vanguard: Current attitudes toward mental illness. Professional
Psychology, 9, 244-248.
Morrison,). K., & Teta, D.C. (1977). Increase of positive self-attributions
by means of demythologizing seminars. journal ofClinical Psychology,
33, 1128-1131.
Nevid,). S., & Morrison,). K. (1976). Attitudes toward mental illness:
The construction ofthe libertarian mental health ideology scale. Un-
published manuscript.
Payton, O. T. (1985). Clinical reasoning process in physical therapy.
Physical Therapy, 65, 924-928.
Politser, P. (1981). Decision analysis and clinical judgments: A re-
evaluation. Medical Decision Making, 1, 361-389.
Rogers, ). C. (1983). Clinical reasoning: The ethics, science and art.
American journal of Occupational Therapy, 37, 601-616.
Rogers,). c., & Masagatani, G. (1982). Clinical reasoning of occupational
therapists during the initial assessment of physically disabled patients.
Occupational Therapy journal of Research, 2, 195-219.
162 BARRIS

Schon, D. A. (1983). The reflective practitioner. New York: Basic Books.

Watts, N. T. (1985). Decision analysis: A tool for improving physical
therapy practice and education. In S. Wolf (Ed.), Clinical decision-
making in physical therapy (pp. 7-24). Philadelphia, PA: F. A. Davis.