PRACTICE EPISTEMOLOGY APPLIED TO OCCUPATIONAL THERAPY IN THE FORENSIC SETTING

The practice context applied to explore Cook and Wagenaar’s (2012) theory of a practice epistemology is that of public administrators in the form of detectives in a police force and the development of a criminal case. In order to demonstrate whether Cook and Wagenaar’s conceptualisations are a useful fit for occupational therapy I apply them to my practice experience as a former occupational therapist in forensic mental health, based on an overview of usual aspects of my practice. As previously stated, my experience indicated the limitations of rational, evidence based approaches and the need for a more inclusive definition of knowledge as evidence.

Cook and Wagenaar’s (2012) work is combined with, amongst others, the American pragmatist philosophy of Dewey and Peirce and two Japanese philosophers’ work (Nishida, 1911/1990 and Watsuji, 1935/1961 cited in Cook and Wagenaar, 2012, p. 23) and also by Zen philosophy. Borrowed from Japanese philosophy is the belief that knowledge is non-dualist, with relationships in philosophy seen as fluid and dynamic. These are used to reframe the position of knowledge and practice as seen in the Cartesian and Received Views, thus

conceptualising an epistemology of practice (see figures 9 and 10) (Cook and Wagenaar, 2012). Professional knowledge is increasingly being seen as created in situ, through practise (Cook and Wagenaar, 2012). Thus two key views of Cook and Wagenaar (2012) are presented. Firstly that knowledge is inclusive in that it incorporates forms of knowledge such as embodied, engaged and contextualised agency. Secondly that their view of an epistemology of practice includes inquiry that incorporates these knowledge forms, and acknowledges the constraints and possibilities in or of practice (Cook and Wagenaar, 2012).

Figure 9. An epistemology of practice (source: Cook and Wagenaar, 2012, p. 18)

There are three interrelated concepts that represent practice: ‘actionable understanding’, ‘eternally unfolding present’, and ‘on-going business’ (Cook and Wagenaar, 2012). Practice is about actionable understanding that is informed by a constantly renewed past, and is directed at what is always a partially decipherable future. This is situated in a present that is eternally unfolding and acted upon within the on-going business of action. In the following section, I will flesh out each of these concepts and apply each one in turn to my practice experience in occupational therapy in forensic mental health.

Figure 10. An epistemology of practice (source: Cordingley, after Cook and Wagenaar, 2012)

Actionable understanding accounts for what practitioners do and is explained in

terms of the practitioner. The practitioner understands what is known or needs to be known, but knowledge in itself does not direct what is done. Actionable understanding involves the process of mutual understanding of a case, which is constructed by practitioners, and along with the joint achievements of practitioners, enables taking acceptable actions. The case, in the forensic setting, may represent a service user, or given the large amount of group-work involved in occupational therapy, the case may also represent a group of service users. Actionable understanding can be facilitated and constrained by the various rights, responsibilities and expectations of the practitioners both within the practitioner’s working world and also in the wider outside world.

Underlying this process is that a form of practice is generated where existing knowledge may be deployed. Within this sphere, a new knowledge may also be created, but it is not primarily a matter of applying knowledge to practice. Practice is seen as primary and knowledge is a tool of and has utility within practice.

Figure 11. Actionable understanding (source: Cordingley, after Cook and Wagenaar, 2012)

Actionable understanding is explored next in relation to my practice experience in

occupational therapy within the forensic mental health field and through the mutual understandings between team members and me.

Actionable understanding and my practice experience of occupational therapy in forensic mental health

I had a number of actions to complete that represented work to be done with most service users, also an element of on-going business, discussed later. The wider organisational and team expectations meant that I worked with a blanket referral approach where all service users were seen by me. My professional code of conduct also required me to use the occupational therapy process to structure my practice (COT, 2015). This guides practice and includes: referral, assessment, intervention planning, intervention, evaluation and discharge (Lloyd, 1985; 1987 a, b, c and d). One thing I did was to remain alert until I could act at a specific point. For instance, I would listen for potential referrals to the ward and team, as they were briefly highlighted in each multi-disciplinary team meeting. Then I would wait to hear about any new admission plans. A service user’s admission would trigger me to attend a review of the service user’s history presented in the first multi- disciplinary team meeting following their admission I would start to complete an admission summary sheet (see appendix 1) also review and organise preliminary information such as previous psychiatric reports, index offence details; police interview transcripts of both service user and witness statements and on occasion, photographs of the crime scene. I reviewed this information for the details relevant to occupational therapy in that setting. I sourced previous admission details and occupational therapy notes and reports from other services. Actionable

understanding here meant that my actions were to read, review, collate and

organise information relevant to my practice from a wide range of sources.

An example of actionable understanding, where I developed ways of doing things from the experience of that practice setting, were concerned with my plans for the potential direction that the occupational therapy process might take. I did not always follow this process as stated in the literature. I found I needed to consider the point at which to make contact with the service user and what form that contact would take, which sometimes came before I had even reviewed or discussed the service user’s history (as in Bob’s vignette). I usually reviewed other professionals’ work first, and considered the service users’ mental state and their stated wishes (if known) before deciding on an initial plan of action. Often the service user had come from prison, was acutely unwell, had not had much contact with friends or family and had difficulties sorting out financial and social needs related to their

home circumstances. It was better for me to wait until these issues were dealt with and the service user was less concerned by such matters. My actionable

understanding would therefore be informed by whether I thought the service user

required more input from nurses, psychiatrists and/or social workers before I made formal contact. I would thus remain alert to the service user’s improvements, but also utilise the practice context and service user’s behaviour to initiate less formal contact because I would see service users on the ward before I carried out any formal work.

Making first contact could be influenced by whether I was familiar with the service user from a previous admission, and what their mental state was as reported by other disciplines. Indeed, I was based in an office on the ward and to gain access I had to walk through it, and there were many occasions when I ‘bumped’ into a new service user on the ward and introduced myself before I had any detailed knowledge of their current situation, for example in Bob’s vignette. This could be due to an emergency admission occurring before the team could be informed in a ward round.

I started to build a picture of the service user, identifying my working hypotheses of what were the potential occupational participation needs and skills and possible reasons why these had developed in that way.

Actionable understanding in occupational therapy therefore signifies that multi-

disciplinary team members would have a broad understanding of each other’s process. Indeed, the first vignette of John’s case history is an example of mutual understanding where that information is needed by all members to varying degrees to inform their practice. Mutual understanding also manifests where the team will have some knowledge of a specific aspect of others’ work from discussions in clinical team meetings, joint assessments, and joint working on particular pieces of therapeutic work. Team members, of course, have varying degrees of depth of understanding of each other’s discipline, but it is through the team’s work with the service user that the practice of each discipline becomes increasingly apparent. It is within this context, where team members have various degrees of experience, that the specifics of each new service user, with their unique characteristics, demand the development of innovative and different ways of working, thus creating a new knowledge from practice.

One example of this mutual understanding that also became part of my new knowledge and of the different ways of working was from a discussion between the team that ultimately progressed to me and the consultant psychiatrist. The team were challenged about a service user called Charlie whom we could not engage in basic self-care tasks. He had developed substantial body odour and this was becoming a wider problem because his room was also becoming malodorous to the extent that it seeped into the surrounding ward corridor. Other service users were complaining, and some were verbally and physically targeting Charlie. He therefore became a target for harm by other service users, plus he had possible hygiene problems. The nurses usually took a lead in self-care with the service users. They had great difficulty educating and encouraging Charlie to understand the issues that were arising due to this form of self-neglect. Neither could they motivate Charlie to keep clean. The psychiatrist had knowledge of occupational therapists working within neurology and people who had experienced head injuries and strokes. Charlie had a head injury some years prior to his admission to the unit, and his routines on the unit were mainly to make tea, smoke in the allocated lounge and to spend much of his day in his bedroom. It was therefore difficult to establish his performance skills of problem solving and managing activities. He had been observed performing basic tasks of making a hot drink, rolling cigarettes and basic money management. The psychiatrist suggested I look into cognitive problems of executive dysfunction possibly affecting his ability to recognise his behaviours and the impact they were having on others. This was new knowledge to me and prior to my experience with the CASP project mentioned in my preface. Consequently, I spoke to an occupational therapist working in neurology. She explained executive dysfunction in head injury, how it manifested in occupational participation and how I could assess for related participation problems. On the basis of this new knowledge I set about making a plan with Charlie’s primary nurse to explore the situation with Charlie.

Here was a situation where the psychiatrist’s knowledge and experience of occupational therapy in neurology that was not connected to the mental health setting, was used to develop my knowledge. This was also facilitated by the psychiatrist’s existing knowledge of my role. My knowledge of occupational therapy was enough to facilitate my further understanding when combined with knowledge from the therapist working in an unrelated practice area of neurology. Without such

mutual understanding between practitioners, prompted by Charlie and his complex neurological and mental health problems, this actionable understanding would not have arisen.

The next concept is the eternally unfolding present which is an acknowledgement of the temporal elements where practice is seen as necessarily occurring in the present (Cook and Wagenaar, 2012). Discussion about a case between disciplines takes place in the present and this dialogue is seen as a component of practice occurring in the present (Cook and Wagenaar, 2012). Cook and Wagenaar (2012) were concerned that identifying practice as contemporaneous may be seen as trivial and may have been taken for granted. This is because to state talking occurs in the present appears obvious, and also because discussion may be perceived as a superficial aspect of practice that does not deal with deeper issues. In the

eternally unfolding present, knowledge and context take their form and meaning

from practice and so are artefacts of practice. So Cook and Wagenaar’s (2012) approach has a fundamental epistemological position that means knowledge does not underlie and enable practice.

Figure 12. Eternally unfolding present (source: Cordingley, after Cook and Wagenaar, 2012)

Occupational therapy in forensic practice occurring in the eternally unfolding

present becomes apparent at the admission to the ward of a service user that leads

to the start of the occupational therapy process (Lloyd, 1985; 1987 a, b, c and d). A specific part of this process is worked on at any one time, so the impression of a linear or cyclical process is misleading because the focus might be on collecting

further information later in the service user’s admission, which would be out of kilter ‘with the information gathering process at the beginning of the cycle. One of my early experiences on a ward demonstrates this and also provides examples about

actionable understanding and on-going business.

Vignette 3. Ben and an example of the eternally unfolding present

A service user Ben, had been low in mood, was very quiet and had been mostly staying in his room which I knew from the morning handover of nurses’ information. At this point I had not had direct contact with Ben, which was not unusual with this presentation in the early days of a new admission. From Ben’s admission details given in the team meeting I knew that he had worked as a cook prior to his admission. At this time I had no direct observations of Ben’s current occupational participation skills and constraints. That morning I was doing a breakfast cookery session with two other service users in the ward kitchen. The ward policy was to have open access to the kitchen for all service users to make hot drinks and snacks. I was concentrating on two service users cooking fried breakfasts on the cooker hob. Ben entered the kitchen to make some breakfast. Ben made a hot drink and put some bread in the toaster. Given my focus on the other two service users, who required support, I had no opportunity to observe Ben’s skills in this basic kitchen task. I made the assumption this would be fine because he was a cook and therefore had some culinary skills. I also assumed that as the kitchen was open access and the nursing staff had no specific concerns about Ben using the kitchen, it was fine for him to go ahead. He was using a different part of the large kitchen and the facilities he needed were not being used by the other service users. During this time another service user, Tony, entered the kitchen in a rush. He was followed swiftly by a nurse who tried to get Tony to stop until there was a bit more space in the kitchen. Tony ignored the nurse and went directly to the drink ingredients and started to make a hot drink. I was therefore suddenly distracted by Tony who appeared to be in a highly elated mood, and who was not paying attention to others’ requests. It was not until I smelt burning, turned around to see smoke coming from the toaster and then hearing the ward fire alarm went off that I realised I had been distracted from trying to monitor Ben from a distance.

Ben’s most basic cooking skills were therefore not intact at that time. My assessment of Ben’s impaired participation and Tony’s elation stems from the

nursing handover that indicated both were acutely unwell. There was no indication from the nurses’ observations of Ben and Tony that they were presenting with behaviour that might indicate that they were more unwell than they were. It seemed to me too far-fetched that Tony and Ben had planned to cause the chaos in the kitchen, because Tony and Ben were consistently acutely unwell. Also, given Ben had been successfully employed as a cook, it indicated that his abilities may have been impacted by his acute mental health problems. This was an indication to me that I needed to further assess Ben’s skills, especially if he was likely to continue to be a risk to accidentally causing a fire on the ward.

The scenario with Ben and Tony provides an example of my practice in the

eternally unfolding present where my expectations were not met, and what I

thought were reasonable assumptions about a service user, the situation I was in, and what the service users and I were doing. As a concept, the eternally unfolding present is apparent here for two reasons. Firstly I could not predict the situation occurring. I was not to know that the combination of people with their individual characteristics, that were not fully apparent to me, combined with my lack of practice knowledge of that context, at that time, in that particular kitchen environment, were a potential danger. My practice experience and resulting knowledge were contextualised through the specific combination of the people, what we were doing, the events and the environment. Secondly, this practice experience is so specific it could not have been available to me in a codified way through practice guidelines, textbooks and journal articles. In an abstract form, aspects that I was aware of included some of my core skills as an occupational therapist: activity and environmental analysis and adaptation. I considered the analyses prior to the breakfast cookery, and I found I would not be required to adapt the environment and activity at that time when working with the two service users. Tony’s elated mood and presence brought much of this into question, especially with the unexpected and unpredictable dimensions that can be part of the eternally

unfolding present.

What can be gained from applying the eternally unfolding present to my practice experience is that it produced a new knowledge for me, created from my practice at that point. It indicates that I wanted to maintain the ward policy to keep the kitchen and service users’ access as restriction free as possible. This relates to my belief, as an occupational therapist, that I want to maintain service users’ daily living

skills as far as possible. Restricting access to the kitchen environment would have impeded this belief and my approach.

What turned out to be a new experience became a new knowledge and I consequently decided that in future cooking sessions I would lock the kitchen door to prevent access by un-well service users. If service users wanted to make breakfast, I asked them to wait until others in the kitchen were finished and I could then provide access in a controlled environment as well as have the opportunity to observe the un-well service user’s skills, and provide support as required. At the same time I adapted the physical environment and provided access for all service users to hot and cold drink facilities through a large opening in the wall between the kitchen and day area.

Characteristics of on-going business include a stable state where professional practice is about business as usual, as well as an emergent nature of practice. Therefore on-going business is made up of the shared experience of practitioners,