Application of dual process clinical reasoning to activity analysis

I had my first class at UniSA yesterday. It included six first year occupational therapy students doing an activity analysis of a woman hanging a sheet on her washing life. This was a wonderful group to have some in depth conversations with. I love first years, especially when they include practice managers, creative animators, sleep specialists, students of neuroscience, adventurers, and a young person who has left HongKong for political reasons. The profession is going to be in good hands, it seems to me.

It feels auspicious that the very first class was about activity analysis, which is the most fundamental tool of occupational therapists. The students were asked to watch a video of someone hanging up washing on a line and folding it as they took it off. This woman uses a clever folding technique that is aimed at avoiding ironing and the middle step of a pile of unfolded clothes that sits around for a week.

The aim of this kind of activity analysis is to train occupational therapists to be deeply observant about the activities that are normally invisible. This is a fundamental skill used to develop occupational therapy interventions, allowing clinicians to analyse and break down a task in a systematic way (Creighton, 1992). Task analysis consists of the development of a set of steps required to complete the task, and the skills, abilities, and knowledge used (Yuen, 1998). Activity analysis arose originally from the ‘time and motion’ studies initiated about 1917, which were methodologies used to study the movements of workers on the job (Taylor, 1911).

In occupational therapy, there is usually a distinction between activity and occupation – as units of analysis (Thomas, 2015). For example, an activity would be making a peanut butter sandwich; whereas, an occupation would be a mother making a peanut butter sandwich for her child at home. Occupation analysis therefore requires a deep understanding of what the activity enables, who the person is and what the environment is like. Understanding of the skills, abilities, and knowledge used in completion of a task or occupation contributes to the OT’s clinical reasoning process.

One way to look at how we understand this difference in the kinds of reasoning required for analysing occupation or activity is to describe what is learned through deductive and inductive observations. In deductive observations you examine what is being done against an ideal, and observe the extent to which there are deviations against a specific theoretical ideal. In an inductive approach, you watch how someone does an activity and you infer from their movements a whole story about how and why they are how they are. In other words the main difference between inductive and deductive reasoning is that inductive reasoning aims at developing a theory (what is this person like?) while deductive reasoning aims at testing an existing theory (how well does this person perform against specific criteria). Inductive reasoning moves from specific observations to broad generalizations (I’ve watched the woman hang up her washing and now I have a whole story about her), and deductive reasoning the other way around (I watch a woman hang up her washing and now I know how well she hangs up her washing).

Another ways of describing inductive and deductive reasoning to to think of them as top down (inductive) or bottom up (deductive). The top down approach sees a whole person hanging up the washing, and then works out from there what her strengths and weaknesses are. The bottom up approach watches the person carrying out an activity frame by frame, and this way is able to achieve precise evidence of the kind of problems that this person has, as well as their precise strengths. Both approaches can work in our clinical reasoning.

In the literature there is an increasing emphasis on calling these types of reasoning: type 1 and type 2 thinking. This comes from early psychological theory (William James, 1890). According to this model, two types of mental processes exist, that jointly work together. These are called (Type 1): a fast, non-analytical, intuitive, heavily based on pattern recognition. This is described as ‘intuitive, tacit and experiential’. It is rapid and seems to be automatic, working on the principle of recognition. It is highly dependent on contextual cues, and it is compared to a ‘gut feeling’. The other (Type 2): slow, analytical, hypothetico-deductive, involving a conscious explicit analytical approach. It depends of rational and deliberate judgement which is based on additional information collected activity, and the it uses rules that have been acquired by learning (Pelaccia et al 2011)

There is a problem with this separation between type 1 and type 2 reasoning about the woman who hangs up her clothes. This is because the occupational therapist who watches one task with deductive eyes is going to make assumptions about the observed categories. Therefore, if she observes that there are musculoskeletal problems in hanging up the washing, she is going to assume that these musculoskeletal problems also happen when she is doing a whole range of other tasks. In a sense she then makes up a whole narrative about the musculoskeletal reality of this woman on the basis of a small piece of evidence (hanging up the washing). In the end, both inductive and deductive processes aim to achieve an understanding of the person. It is a diagnostic and practice skill.

So, there is not a simple division between type 1 and type 2 reasoning. However, I believe that we are on the right track with what we are doing. We just need to get a bit more sophisticated about making the connection between activity analysis and clinical reasoning. This is our very special area of contribution to the literature. It feels to me sometimes that we have not even started to do what is necessary. Where is our encyclopedia of activities that have been analysed? (this would be easy enough to put together from YouTube type videos); these encyclopedia entries should be accompanied by analysis of what it is like to do these activities with specific disabilities. This would provide a frame of reference for all the things that need to be taken into account when helping someone to engage in an activity.

Of course this is only a small part of occupational therapy – but it is the small part that makes all the difference. If this kind of encyclopedia of activities was available, it might then be possible to analyse what different levels of support would look and feel like. Such a tool would have obvious utility to systems like NDIS, who are constantly asking occupational therapists to do a functional analysis – with levels of support as the bottom line.

This is the kind of project that occupational therapy programs could collaborate to achieve internationally. For example, most programs have a course where students are asked to learn a new activity. The analysis of this activity could become the basis of the library. Then gradually experts with disability could start to fill in the activities, using a talk through technique.

Creighton, C. (1992). The origin and evolution of activity analysis. American Journal of Occupational Therapy 46:45-48. doi:10.5014/ajot.46.1.45.
Pelaccia, T., Tardif, J., Triby, E., & Charlin, B. (2011). An analysis of clinical reasoning through a recent and comprehensive approach: The dual-process theory. Medical Education Online, 16(1).

Thomas, 2015. Introduction to “Occupation-Based Activity Analysis”, Second Edition, edited by Heather Thomas, SLACK, Incorporated, 2015. ProQuest Ebook Central,
Created from unisa on 2022-05-22 04:01:19.