Thinking in Stories: Narrative Reasoning of an Occupational Therapist Supporting People with Profound Intellectual Disabilities’ Engagement in Occupation

Abstract

This article illustrates narrative reasoning using the findings from research into an occupational therapy intervention promoting changes in the ways a staff team facilitated meaningful engagement in occupation. Qualitative critical ethnographic case study research explored a single case over one year of an occupational therapist working with five people with profound intellectual disabilities and their support network. Data were collected using participant observation, interviews and document analysis. Illustrated by an ethnodramatic vignette, the findings demonstrate how the occupational therapist reasoned narratively by eliciting, telling and creating stories and how this supported individualization of her intervention to the specific context. Creation of a prospective story that the support network were invited to share, guided and propelled the intervention toward its hoped-for ending. Narrative reasoning was particularly apparent in opportunities to reflect aloud, supporting occupational therapists’ need of opportunities for reflection through story-sharing and story-making. Case study and ethnographic research methodologies may be useful in further clinical reasoning research to better understand narrative reasoning.

Keywords:

• Case study methodology
• clinical reasoning
• ethnodrama
• ethnography
• narrative reasoning
• occupational therapy
• qualitative

Introduction

The complex clinical reasoning said to be carried out by occupational therapists when supporting occupational engagement has been conceptualized in different ways. It can be seen as both a cognitive and interactive process (Higgs & Jones, 2019), with a multitude of different modes of reasoning identified, including scientific, diagnostic, procedural, narrative, pragmatic, ethical, interactive, and conditional (Unsworth & Baker, 2016). Procedural, scientific and diagnostic reasoning, involve problem-solving by diagnosis, pattern recognition and hypothesis testing (Schell & Cervero, 1993), whereas by contrast, narrative reasoning is a ‘deeply phenomenological mode of thinking’ (Unsworth, 2005, p. 32) . This allows interventions to be personalized in response to what really matters to an individual, turning them into an actor as opposed to a ‘mere ‘body’ acted upon by others’ (Mattingly, 1998, p. 137). This article illustrates the narrative reasoning of an occupational therapist working with five people with profound intellectual disabilities and demonstrates how such reasoning became visible in the findings from qualitative ethnographic case study research.

Narrative reasoning

Narrative reasoning is often described as an individual’s narrative, story, or occupational history and incorporating their personal perspectives on their experiences to reach collaborative understanding (Caeiro et al., 2014; Higgs & Jones, 2019). Within this broad sense however, three more specific dimensions of clinical reasoning are identified by Mattingly and Fleming (1994). Interactive reasoning is the interpersonal process (Crabtree, 2010) of developing a shared understanding of someone as a person and individualizing their intervention (Fleming, 1991). Conditional reasoning is the complex form of reasoning that creates meaningful wholes (Unsworth, 2004) by making sense of everything known about the person with whom one is working (Fleming, 1991). Finally, Mattingly’s more specific understanding of narrative reasoning (Mattingly, 1998) involves thinking in stories and is the focus of this paper.

Mattingly (1991, 1998) noted that the occupational therapists she observed and interviewed in her ethnographic research reasoned narratively not just by eliciting stories of those they were working with, but also through thinking in stories in two different ways. As well as literally telling stories of their clinical experiences to others, they additionally engaged in a more subtle form of narrative reasoning that involved creation of stories. They pictured future images of who their patients could be thereby creating a ‘prospective treatment story’ (Mattingly, 1991, p. 1001). Mattingly described how such stories drove occupational therapists’ interventions and how clinical problems and treatment activities were organized in their minds in the form of ‘unfolding’ stories or dramas (Mattingly, 1998, p. 64).

Fleming (1991) theorizes this specific understanding of narrative reasoning as the foundation for interactive and conditional modes of reasoning. It is notable, however, how infrequently it appears in the findings of other clinical reasoning research. Coe (1999) does reflect on such narrative reasoning in her own involvement in a young woman’s rehabilitation and Shepherd (2017) refers to it briefly in her work with an individual with profound intellectual disabilities. Often, however, when authors do identify narrative reasoning (e.g., Carr et al., 1995; Schell & Cervero, 1993) they seem to be using a broader definition of the concept and in fact identifying interactive and/or conditional reasoning. Carrier et al.’s review (2010) makes reference to occupational therapists telling stories, but not to creating them. Unsworth (2004; 2005; 2011) refers to narrative reasoning using Mattingly’s interpretation in the introductions of three research articles. When analyzing her interviews, however, Unsworth did not code this as a separate form of reasoning, coding instead for interactive and conditional reasoning and seemingly viewing the entire research interviews as ‘stories’ of therapy sessions. Lyons and Crepeau (2001) similarly did not code for narrative reasoning and it was not evidenced in a study of mental health group work (Ward, 2003).

Despite this limited representation of narrative reasoning in the ‘thinking in stories’ perspective in recent research, it is nonetheless emphasized theoretically in clinical reasoning papers (e.g., Bonsall, 2012) and current textbooks on the subject (e.g., Hamilton, 2017; Mattingly & Fleming, 2019). The extent, however, to which this theoretical type of reasoning is actually evident more widely in occupational therapists’ practice remains unclear. To be able to recognize and better understand it, further evidence of its existence and illustration is required. This article describes how such narrative reasoning became visible in the findings of qualitative case study research exploring an occupational therapist’s work with five people with profound intellectual disabilities and their support workers to promote engagement in occupation at home.

Background to the study

People with profound intellectual disabilities have a high level of cognitive impairment, typically alongside complex health needs, additional physical disabilities and communication abilities limited to early developmental levels. To engage in occupation, they need significant, skilled day-to-day support recognizing individual abilities and likely developmental levels of engagement (Mansell et al., 2003). The home presents many opportunities for involvement in ordinary daily activities such as cooking, cleaning, gardening and self-care (Cameron & Murphy, 2007) and the right type of support can facilitate partial, though meaningful engagement in such activities. However, low levels of meaningful engagement in occupation by people with profound intellectual disabilities have long been reported in the UK, Australia, Norway and Sweden (Borland et al., 2020; Kåhlin et al., 2016; Mencap, 2011; Murphy et al., 2017; Witsø & Hauger, 2020). Occupation can be lost in a setting that focuses on meeting individuals’ physical and health needs and a ‘hotel’ model of care may result with staff cooking and cleaning while they are inactive. Occupational injustice arguably occurs when the practices of individual support workers (or the systems within which they work) result in lack of engagement opportunities available to others. Occupational therapists have a key role in supporting meaningful engagement in activity or occupation, often through improving the practices of those providing direct support (Lillywhite & Haines, 2010; Perez et al., 2012; Tannous et al., 1999).

Thus the aim of this research was to understand the different forms of an occupational therapists’ practice, including the reasoning underpinning actions as the approach was adapted to the specific context. This paper focuses specifically on exploring the therapist’s narrative reasoning in order to provide a detailed illustration of reasoning of this type.

Methods

Design

A critical ethnographic case study methodology was used with multiple data collection methods (e.g., participant observation, interviews, document/artifact analysis) to explore a single purposively-selected case of occupational therapy. Specifically, an occupational therapist worked with five people with profound intellectual disabilities and the staff team supporting them to increase engagement in occupation at home. Case study methodology classically establishes ‘the how and why of a complex human situation’ (Yin, 2018, p. 9) and generates in-depth understanding from multiple perspectives (Simons, 2009).

This qualitative case study research (Thomas, 2015) supported construction of a case that is both exemplary – as a good example of occupational therapy - and instrumental in facilitating readers’ in depth understanding (Simons, 2009) with the aim of bringing the case to life. Interpretivism and social constructionism placed the researcher centrally in the research, constructing findings jointly with participants as ‘interpreter and gatherer of interpretations’ (Stake, 2008, p. 135). Trustworthiness was promoted by prolonged engagement over the course of one year, persistent observation of emerging issues, and iterative opportunity to check raw data and initial conclusions with sources (Simons, 2009). The case is critical and ethnographic in its thick description and explanation of culture and structure and of arguable injustice within the setting (Madison, 2019).

Participants

All participants and places are referred to by pseudonym. Interest was sought from experienced occupational therapists and Esther, an occupational therapist from a community team for adults with intellectual disabilities in England volunteered. Her work at ‘Cavendish House’ with Matt, Steve, Becky, Jane and Harold, five adults with profound intellectual disabilities became the case of occupational therapy supporting engagement in activity at home that is the focus of this research.

A series of carefully planned recruitment procedures ensured compliance with the Mental Capacity Act (GB Parliament, 2005) in recruiting Matt, Becky, Harold, Jane and Steve. Further participants were recruited purposively as Esther worked with them and included an occupational therapy assistant, ten support workers, a community intellectual disabilities nurse and the managers of Cavendish House.

Ethics

Obtaining ethical approval was complex as the evolving nature of case study research makes full explanation for ethics committees and prospective participants challenging and because participants Matt, Becky, Harold, Jane and Steve had profound intellectual disabilities. Esther and colleagues concluded that no amount of adaptation of the presentation of recruitment information could maximize their capacity sufficiently to allow them to make the decision about participation themselves. Best interests decisions about participation in accordance with sections 30-33 of the Mental Capacity Act 2005 (GB Parliament, 2005) were therefore made. These were justified by the need for insight into the experiences of those lacking capacity in order to develop a research evidence base for how best to support them (Tuffrey-Wijne et al., 2008). Appropriate consultees were sought and they agreed that the presence of a researcher would be unlikely to be experienced as unusual and that research methods were similar to and no riskier than the routine support they received (Dalton & McVilly, 2004).

Data collection

Data collection methods were characteristic of case study and ethnographic research. The first author spent significant time over the course of one year in the field with Esther, taking on the role of ‘observer as participant’ in Gold’s typology of participant observer roles (Gold, 1958, p. 217). The data set included jottings and field notes from his 17 observations of Esther’s work with those in the house, along with full transcripts of 25 formal interviews with her, support workers and managers. Some interviews were pre-arranged, others relatively informal, opportunistic conversations, exploring observed aspects of the case. Videoing was used in a reflective modality such as playing recorded aspects of practice back to Esther in interviews that facilitated her reflection and allowed exploration of her tacit understandings and reasoning. Reports, activity support guides and other documents and artifacts created by her were also explored in the interviews. Using multiple data sources recognized the case’s complexity and contributed to identification of different converging and diverging realities, including assisting interpretation of observations through gaining interviewees’ own perspectives. Data collection came to a natural end once Esther completed her work, approximately one year after her involvement in Cavendish House began.

Analysis

An emergent, though systematic and inductive thematic analysis (Bazeley, 2020; Braun & Clarke, 2013) of the data allowed construction of a conceptual, rather than purely descriptive, account of the case. Interpreting as much as analyzing (Stake, 1995), findings were constructed jointly with participants (Thomas, 2015), notably Esther. Key to ensuring trustworthiness was reflexivity throughout.

NVivo 12 computer-assisted qualitative data analysis software (QSR., 2019) supported a process of formal and more intuitive analysis, in particular repeated coding and categorizing of the data (Saldaña, 2015) to organize and make sense of it. The data were openly coded, then organized in increasingly interpretive and conceptual ways. Definitions of codes, with examples of text, formed a code book of some 450 codes, gradually organized into a framework of trees and branches. Constant comparative analysis involved movement back and forth between codes, categories, themes and the data. Writing analytic memos supported refinement of ideas, whilst gradually shifting to a deeper, more conceptual analysis, paying more particular attention to broader patterns and eventually identifying themes.

Complementing the coding of processes, it was insightful also to focus on narrative aspects of the case, with dramaturgical coding particularly relevant to case study research (Saldaña, 2011, 2015). Specific episodes observed and narratives in interviews, particularly those involving participants acting, reacting and interacting, could be seen as performance or social drama. Consciously considering dramaturgical concepts such as cast of characters, monologue, dialogue, soliloquy, scenario, script and plot devices attuned the first author to the qualities, perspectives and drives of participants and their objectives, tactics and attitudes. This was particularly insightful into Esther’s reasoning and outcomes of this are visible in the vignette in the findings below.

Findings

At the start, Esther had worked in the local community intellectual disabilities team for about 12 years, previously working with Matt (ten years before) and Harold (the previous year). Frustrated that previous work with Matt and Harold had not sustained increased levels of engagement, Esther took participation in this research as an opportunity for extensive occupational therapy input with all five residents and their support team. She aimed for them to adopt a different way of working, which would involve them focusing on the sensory aspects of daily living activities at home and hoped for more sustained outcomes by engaging them in a ‘project’ over the course of a year.

The findings take the form of a story of the case with two overarching themes: (1) how shifting support and leadership cultures in Cavendish House impacted on engagement in occupation and on recommendations being implemented by the team; and (2) characteristics of an occupational therapy intervention that sought to create and sustain cultural change by collaborating with and empowering support workers. This paper focuses on Esther’s narrative reasoning as she made efforts to embed a different approach to supporting engagement in occupation in the work of the team.

In an effort to ‘depict experience … with such veracity that others will have vicarious experience’ (Simons, 2009, p. 158), the following vignette draws on encouragement to use ethnodramatic play scripts as presentational methods for qualitative research findings (Saldaña, 2011). It is constructed in the form of a monologue using Esther’s words from the interviews and although re-ordered, these words are otherwise edited only sufficiently for the script to flow.

The vignette – a journey together: Esther’s monologue

Scene 1: The project – a journey together

[passionately] I have come to this point where I am going ‘no, a project will be better’. What I want to do is to get it into the culture, I want to get everyone thinking about sensory activity, getting it embedded into everything and getting them excited. To start with, there is probably quite a long journey to make before they are thinking about this every day. And it feeling like it is a joint venture. You have got to get people on side with you, so they feel comfortable that I am going in and we work together on it and it doesn’t feel threatening. I want that to be a supportive process, a journey together to improve it.

Scene 2: No one is really doing anything

[sighs, quieter, slowly] Ummm I have kind of abandoned the idea of them showing me what they do, cos whenever we turn up no one is really doing anything and when you ask them ‘what do they normally do’, they always say ‘go out’, don’t they? [rolls eyes]

And it is so hard to get to a staff meeting! It is taking weeks to set up. Maybe I’m pinning too much on meeting them as a whole group and should be speaking to them individually?

Scene 3: Training with a small ‘t’

[excitedly] I’ll tell you about the training I did, the workshop. You know I wasn’t at all hopeful, it has been canceled loads of times, hasn’t it? But it was really, really brilliant.

I was thinking of [mimes inverted commas] ‘training with a small t’, a little bit of information giving about how people with intellectual disabilities engage with activities and get them to tell me where they think those guys are functioning. And I really felt like it was a bit of a journey and so I said ‘I’ve set these goals, are they realistic?’ and they said ‘yes’, so I thought that was a bit of a win really. And then they were all coming up with these ideas and a lot of discussion at the end. The fact that they were even thinking about those practical things made me feel really more confident. It felt like there was some energy and like we were on a journey together. It is about finding allies, isn’t it? Once you’ve got one person on board and they are talking about it when you’re not there, it starts to spill over and other people start to hear it and it is not just coming from us.

Scene 4: A turning point

I think that was a bit of a turning point! [laughs] I was just about to go and one of the members of staff kind of ran after me and said:

‘hold on, I want to talk to you about something. we need your advice and help about how we are going to make Harold’s bath times sensory. Also, we have been doing some sensory gardening with him, come out and have a look.’

They already had got some ideas, but what was really nice was they were wanting some advice and some support with it.

Scene 5: They become my closest allies

I think unless Sue [Cavendish House Manager] is on board, we are not going to get everybody else on board, are we? Actually, I know that when I have come up against managers like her before and I have spent the time to work with them and to come a little bit closer to the way that they think, they have been my closest allies so you never know I might be able to, I don’t want to say ‘win her round’ cos I think eventually it will end up being her coming a bit closer to what I am trying to say and me having to tweak and compromise. It has opened a dialogue with her. She has seen me, she has talked to me about it, the project is on her radar, so yeah, I do generally feel more positive and I don’t feel like she is actively against it.

Scene 6: I never knew OTs did this

That meeting I had with Sue and Norma [Cavendish House Managers]? I was really happy with it! I said, right I’ll talk through one person in detail and their report plans and goals to give you an idea of where I am coming from. And Sue just went, ‘Ahhh that makes absolute sense, I can really see where you are coming from now.’ And it was almost as if a penny had dropped, you know? She sort of ended by saying ‘this is the most person-centered thing I have ever had, I never knew that OTs did this.’ And she could see how it fits together and how it might enhance what they do. So, I just felt so positive when I left that meeting that I had suddenly won Sue over. Because she will now lead from the top, she will make sure people do it. She is already telling other people who come in that they are doing it. I couldn’t believe that they had invested three hours with me. I really felt in that meeting that both Norma and Sue were listening to what I was saying and making sense of it in terms of their work. I feel so positive that I have won Sue over, but people on the ground also need to feel like they own it.

Scene 7: Teething problems

[frustrated] Oh, days like today I feel really defeated. [pause] I think I have got all these great ideas and I can see how all these things would help the people that live there and then I hit a barrier like that, and I think realistically is it ever going to happen? It is not filtering down very well and the support workers have got less knowledge about the plans than I originally thought. I shouldn’t have to talk to every single member of staff!

[pauses, thinking] But maybe I am beating myself up because it has only been a month and everything takes time to get embedded, doesn’t it? There were bound to be teething problems, there were bound to be people that were a bit more resistant than others. It is not surprising really that they haven’t quite got into it.

[pauses] I won’t stay defeated [laughs] but today I do feel defeated. [pauses, thinking] It is on their radar, it’s definitely on their radar. But I still think there is a shift to be made before they really take ownership of it.

Scene 8: Stepping back – a parting shot

I do need to start stepping back from it now - I think, I need to make them feel like they are responsible and not think I am going to keep coming in to check. We have backed off quite a lot this month. We can’t keep on forever.

I wonder whether this DVD [illustrating each person meaningfully-engaged in occupation] might be my ‘parting shot’. I just feel that it has really captured well five people with different needs and pulls out their different individual things, it looks at communication, it looks at activities. I think that is why it will be so useful as a training resource. It feels having invested all of that time that it all came together and that it is quite a nice summary of the guys and the work. People are more likely to engage with it than a written report. I guess the long-term aim is that Sue and the service will keep this alive and that when they get new staff in the future that they show them the DVD and they talk about it.

Scene 9: Small steps – it is on their radar

I can’t see that it is embedded enough and that really worries me and I don’t know what to do about that. I do feel quite torn about it, it has been a very time intensive piece of work and I do wonder how easy it is to justify the amount of time for the outcome we got. I don’t think we would have got this outcome had we not invested as much time, but I still think we didn’t achieve enough. I mean it is a little bit of that if you aim up here [points high] you get here [points a little lower], because I do think it is on their radar, just the fact that they know when I visit, immediately they are saying ‘sensory’. If nothing else, I have got that.

Narrative reasoning within this case

Viewed through the theoretical lens of Mattingly and Fleming (2019), this “vignette” illustrates three distinct ways in which Esther reasons narratively: by eliciting, telling and creating stories about Matt, Becky, Harold, Jane and Steve and her work with them. It is also apparent how reasoning in this way moves the intervention forward and allows it to be individualized to the specific context.

Seeking stories about Matt, Becky, Harold, Jane and Steve’s lives

The considerable efforts Esther made getting to know each individual well, were apparent from observations, research interviews and her clinical notes. She emphasized how making recommendations about the support each individual needed to engage meaningfully depended on gaining real understanding of skills, strengths, needs, interests and sensory preferences:

You can’t just come in and say ‘we are going to do x’ – you need to take the time to get to know people. (Esther).

Alongside extensive formal assessments and informal observations of individuals engaging in occupation and interacting with and being supported by the staff team, much information was gathered from discussing their lives with those who knew them well (the team, its managers, family members). Although their ability to self-report their own occupational history was limited, eliciting stories about them from others allowed Esther to begin to make some sense of their narratives and the information gained from direct assessment. Seeking stories informed her clinical decision making as she produced individualized plans reflecting personal perspectives, developmental level and sensory preferences.

Telling others about progress

Esther was observed to discuss and report at length on the progress of her evolving intervention, both with colleagues in her team and the first author within research interviews. In telling stories to others, she appeared to be “thinking aloud”. The vignette as a whole illustrates her telling the story of the intervention, including breakthroughs such as successful meetings with the team and Sue and narrative twists such as teething problems with ideas filtering down to the wider team. She invited contributions from her listeners, notably when phrasing her points as questions. Esther herself noted her ideas developing through talking at length in this way about the intervention, recognizing how these discussions facilitated reflection and influenced the decisions she made about her intervention. She likened participating in the research to ‘extensive clinical supervision.’

An imagined ending: A different way of working embedded in the culture of the team

As well as eliciting stories from and telling stories to others, Esther also seemed to be attempting to create a story that those working in the house could share - a ‘journey together’ toward those they supported having different future lives. She spoke of a sufficiently ambitious project to create excitement and momentum, pulling the team together behind agreed objectives. Recognizing that her project could not be endless, she sought to create and sustain cultural change. She had a particular understanding and future images in mind of how Matt, Steve, Harold, Becky and Jane could be supported to engage in activity authentically. Close, responsive relationships and skilled communication would allow them to engage meaningfully in ways that were not merely superficial or tokenistic, with successful engagement more apparent to the team through increased awareness of subtle signs indicative of it. This implied engaging in non-typical ways, her shorthand for which was ‘doing regular things in a very sensory way’ or ‘sensory activity’:

Actually, what I really do want to do is to get them thinking sensory all the time and it becomes more part of their everyday work (Esther).

Esther’s strong desire for change and investment in bringing this about was evident in extensive input into this project. She worked systemically with support workers and managers, seeking to change the team’s outlook on the support they gave and to embed the different way of working into the organizational culture. She made particular efforts to be collaborative rather than directive, supporting them to feel that they ‘owned’ the intervention, rather than having it imposed upon them by her as an outsider, checking agreement and demonstrably making adjustments in response to feedback and obstacles. She empathized with challenges faced by support workers, but nonetheless challenged practice. She encouraged manager Sue and assistant manager Norma to embrace recommendations so that they could ‘lead from the top’ alongside her most motivated allies amongst the support workers. She took time to explain each individual’s reports and recommendations verbally in detail. She modeled the desired approach and created resources to support carrying out activity in recommended ways hoping they might be inspirational ‘building blocks’ to be used and further developed as she gradually stepped back to let the team build on her ideas and take more of a lead.

Within the plot can be seen how Esther’s story keeps evolving. It has conflict and suspense, including the question of whether the ending was even possible to achieve; breakthrough moments such as a three-hour meeting proving to be a turning point when Sue seemingly came to understand what was proposed and how this fitted with her own and her organization’s goals; and (partial) transformation of practice with sensory activity now at least ‘on their radar’.

Discussion

Narrative reasoning by thinking in stories as envisioned by Mattingly and Fleming (1994) is referred to theoretically, but rarely seems visible in clinical reasoning research findings outside of Mattingly’s original work. This study supports this claim that occupational therapists reason in this way. It illustrates an occupational therapist reasoning narratively not only by eliciting and telling stories about her work with five people with profound intellectual disabilities and their support network, but also through creating a story to guide and propel an intervention toward its hoped-for ending. The findings also illustrate how narrative reasoning of this type was particularly apparent in opportunities to reflect aloud.

Reasoning through thinking in stories

Esther elicited stories about the lives of Matt, Becky, Harold, Jane and Steve from those who knew them well. She also told stories of her work with them to colleagues in her team and within the research interviews. Mattingly (1998) noted how the occupational therapists she observed and interviewed reasoned narratively through literally telling stories of their clinical experiences. This study support this description of the story-teller inviting contributions from others who may then respond and offer stories of their own. Such invitations were apparent when Esther literally phrased points as questions or used a questioning tone of voice. In this way, her original stories developed and became co-constructions in collaboration with those to whom they were told.

It was notable how Esther often naturally began to reason narratively when she was struggling to achieve her goal or to make sense of events. This type of reasoning seemed to help her to reach decisions about the direction of her work just as Mattingly highlights how narrative can often guide intervention when there is confusion about the motives behind others’ actions or when progress is elusive. It allowed Esther to explore the motives behind puzzling actions of those working in and managing Cavendish House, such as manager Sue’s initial resistance. Esther gained insight that made this resistance more reasonable or comprehensible. Telling stories helped Esther to work out what kind of story was desirable – or even possible – and how she would need to act in order to bring this about.

Esther’s words suggest very clear and vivid images of what Matt, Steve, Jane, Becky and Harold’s lives could be like and how they might be supported and she gives a sense of an ending to strive for, specifically, a future where sensory activity is embedded into everyday life in the house. This is where a subtler form of narrative reasoning involving creation of stories (Mattingly, 1991, 1998) becomes visible in this case. Mattingly’s participants (1991) similarly described picturing future images of who their patients could be, creating an optimistic and ambitious, forward-thinking narrative, or ‘prospective treatment story’ (Mattingly, 1991, p. 1001) driving the intervention in the form of an ‘unfolding story’ (Mattingly, 1998, p. 64). Esther’s work can be seen as oriented backwards from her imagined ending, with narrative reasoning used continuously to judge how to act and how to direct others’ actions in order to further the plot and reach that ending (Mattingly, 1998).

Elements of the case, for example, the breakthrough moment of Sue’s sudden understanding and support for the project, can be seen as episodes in a larger unfolding drama that became meaningful as they were structured into a coherent plot. It is evident in Esther’s efforts to preserve the plot line and to maintain, or increase, the possibility of reaching the hopeful imagined ending. Mattingly described ‘emplotment’ as the process of ‘rendering and ordering of a succession of events … into parts belonging to a larger narrative whole’ (Mattingly, 1991, p. 1002). This theory is helpful to understand how, through telling and in particular creating stories about her work with Matt, Steve, Jane, Harold and Becky, Esther built an emplotted narrative in the form of a prospective story guiding and carrying forward her evolving project.

Naturally, there was distance to travel between the start of the case and the imagined ending. Mattingly (1998) describes how this gap between where people are and where one hopes they might be provides the impetus for moving forwards. The images some individuals held of the future for those living in the house seemed different to and inconsistent with Esther’s own imagined ending. She was trying to create a story that others also could share, with a similarly meaningful vision of the future. The story is about how Matt, Steve, Jane, Harold and Becky might authentically engage in occupation and the small ways in which independence and choice could be possible. It includes a general portrayal of people who are more than their diagnosis of profound intellectual disabilities and who can be enabled to be human actors, capable of desire and motive and with occupational narratives with agentic plots. As with all good stories (Mattingly, 2007) the plot contains: strong desire for change and investment in bringing this about; conflict, obstacles and suspense about whether the ending will be reached; and in the end, a (partial) transformation.

Critical ethnographic case study research methods

With few examples of narrative reasoning in clinical reasoning research findings since Mattingly’s original research, it may be that certain aspects of this study’s design were key in highlighting how Esther thought in stories. Arocha and Patel (2019) described the most-used methods to investigate the clinical reasoning of health professionals and Unsworth and Baker (2016) and Unsworth (2017) reviewed strategies used to research reasoning more specifically within occupational therapy. As cognitive processes can only be studied indirectly, research is typically qualitative (Unsworth, 2017) . It is either concurrent (therapists writing notes while reviewing a case, or ‘thinking aloud’ by providing a verbal commentary during a session); or retrospective (subsequent recounting of reasoning, either freely-recalled, or with the assistance of stimuli such as audio recordings, or stand-alone/head-mounted video recordings).

Mattingly (1991) describes narrative reasoning as visible in thickly-described actual cases from practice, that are rich in context. The critical ethnographic case study methodology used here produced a thickly-described and context-rich case through the use of contextual and immersive longitudinal methodology, combined with participant observation, interview and artifact analysis. A good proportion of the data was collected by interviewing Esther about her work, including asking her to ‘think aloud’ about it. Beyond this, however, ethnographic participant observation gave additional contextual insight, facilitating access to tacit reasoning. Spending time in Cavendish House and seeing Esther’s work allowed the first researcher to make better sense of her descriptions and allowed him to ask more contextually-relevant questions (or make more contextually-relevant observations) in interviews. Thus, the participant observation informed and contributed to the depth of the interviews and analysis.

Occupational therapists interviewed about their responses to written case studies (Mitchell & Unsworth, 2005) may, for example, have been insufficiently involved in the cases to reason narratively in the way that they might in real life. On the other hand, an ethnographic case study (Park, 2012) exploring interactions in sensory integration-based therapy sessions between an occupational therapist and a child with autism, succeeded in illustrating how an integration of procedural and narrative reasoning led to changes in engagement in activity. Perhaps only methodologies likely to produce experience-near stories of occupational therapy (Mattingly, 2007) and vicarious experience for the reader are likely to evidence narrative reasoning?

Clinical supervision as a space to reflect by thinking in stories

The occupational therapist in this study reasoned narratively as she told and created stories about her intervention within research interviews. She reported finding this a valuable opportunity for reflection-on-action (Schön, 1983), herself likening the research interviews to extensive clinical supervision. Fortune (1999) emphasizes how supervision needs to facilitate story-sharing and story-making and how the ability to learn from reflection requires the re-telling of stories and the co-creation of new stories. The findings from this research lend support to the need for occupational therapists to have good clinical supervision providing opportunity to reflect on practice by allowing space to think in stories.

Limitations

Through the lengthy interviews with Esther, the researcher had a role in co-constructing the story and a different researcher and/or different occupational therapist might have co-constructed a different story. The findings from this single case are therefore not generalizable in a propositional way to the reasoning of all occupational therapists. A rich and detailed depiction of the case hopefully, however, provides the reader with sufficiently vicarious experience to support transferability and naturalistic generalization (Stake, 1995).

To guard against a halo effect whereby feelings can overcome cognitions when appraising others, the researcher tried deliberately to consider Esther’s practice critically and set out to represent multiple perspectives. Sharing an initial version of the story of the case with her proved extremely useful. She confirmed that the rendering felt authentic, whilst also making a small number of suggestions of areas for expansion or clarification. Circumstances allowed only partial gathering of others’ perspectives, as some of the key respondents left Cavendish House. Finally, as an extensive project, the case does not necessarily represent typical occupational therapy practice (especially in resource-scarce times), though it may represent aspirational practice, arguably of the type necessary to achieve intended aims.

Conclusion

Narrative reasoning by thinking in stories as envisaged by Mattingly and Fleming (1994) is referred to theoretically, but rarely seems visible in clinical reasoning research findings outside of their original work. The findings of this study now support the claim that occupational therapists do indeed reason in this way and that this facilitates their clinical decision making and individualization of interventions to specific contexts. They illustrate an occupational therapist reasoning narratively by eliciting and telling stories about her work with five people with profound intellectual disabilities and their support network and through creating a story to guide and propel the intervention toward its hoped-for ending.

It is suggested that it is through opportunities to reflect aloud that narrative reasoning of this type may become visible. It may therefore be important for occupational therapists to have opportunities within their clinical supervision that facilitate learning from reflection through story-sharing and story-making. Future research could investigate the extent to which occupational therapists’ clinical supervision (and other fora where dialogue about practice occurs) are facilitative of narrative reasoning and provide opportunity to reflect on practice by allowing a space to think in stories. The findings also suggest that clinical reasoning research could benefit from using a broader range of methodologies, in particular case study and ethnographic methods more likely to produce experience-near stories of occupational therapy and vicarious experience for the reader.

Ethics statement

This research was approved by the University of Brighton Faculty of Health and Social Sciences Research Ethics and Governance Committee and the National Health Service National Research Ethics Service (NRES) (Ref: 12/LO/0319).

All research participants have been fully anonymized and either consented to participate in the research themselves, or participated on the basis of best interests decisions (as described within the article).

Acknowledgements

The authors would like to acknowledge the support of Dr Huguette Comerasamy.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this paper.

Funding

The author(s) reported there is no funding associated with the work featured in this article.

Additional information

Notes on contributors

David Haines

David joined the University of Brighton in 2006 and was Course Leader of the part-time BSc (Hons) Occupational Therapy between 2012 and 2021. David’s research interests have focused on occupational therapy with people with intellectual disabilities (learning disabilities) and in particular those with complex needs, including profound intellectual and multiple disabilities. He is interested in how we can support and enable people with intellectual disabilities to engage in occupations and how occupational justice can be promoted, in particular through improving the quality of support people receive. In 2015, he completed research for a PhD exploring the ways an occupational therapist supported people with profound and multiple learning disabilities to engage in their occupations at home. David is particularly interested in ethnographic, case study and action research methodologies and in finding ethical means of involving those who may not have capacity as research participants in order that their needs may be researched and their support improved.

Jon Wright

Dr Jon Wright, University of Brighton

Formerly Principal Lecturer in Occupational Therapy at University of Brighton.