The Place of Wisdom in Clinical Practice

Taking a Vygotskyian Approach

In: Practice Wisdom
Author: Rodd Rothwell
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This chapter explores the notion of wisdom and its importance in clinical practice. The question of the place of wisdom in effective professional practice and how it is acquired has been the subject of recent interest among professional educators as well as health professionals. This interest has been motivated by what has been seen by a number of writers as a gap or inadequacy in the conceptualisation and articulation of professional skills and decision making; of what it means to be a good practitioner. Among others, Kemmis (2012), and Kinsella and Pitman (2012b), have expressed concern about the domination in professional training of an instrumentalist positivistic value system. Kinsella and Pitman (2012a) express this concern thus:

We were grappling with a sense that something of fundamental importance – of moral significance – was missing in the vision of what it means to be a professional, and in the ensuing educational aims in professional schools and continuing professional education. (p. 1)

The question I wish to explore in this chapter is what is “missing” or what is the “gap” in professional practice, how is it acquired (can it be taught and learned) and how does it differ from what we may refer to as instrumentalist knowledge or “practical know-how”, that some academics argue dominates profession practice and professional decision making? To address this goal I will firstly overview some current work that seeks to address this gap in practice by drawing on Aristotle’s notion of practical wisdom (phrónêsis) as a model for professional judgement and decision making. Following this I will explore how certain current practices in the professions serve to diminish the role of practical wisdom and encourage a positivistic oriented techno-scientific approach. I will argue that the Evidence–Based Practice movement which has expanded into most professions and many non-professional areas has served with its “means ends” philosophy to reduce the role of professional decision making. Thirdly, I will offer some suggestions of how practical wisdom may be restored to practice – how it may be acquired – by an exploration of the work of the Russian psychologist/philosopher Vygotsky. I will suggest that Vygotsky’s notion of the Zone of Proximal Development (ZPD) may offer a model for the acquisition of practical wisdom.

Much of the work on characterising this missing quality of practical wisdom has been in the field of education which has highlighted aspects of teaching and judgements that require more than abstract knowledge and a set of (or a list of) abstract skills or competencies. Some academics in the professional practice field refer to this additional requirement as “practical wisdom”. Cooke and Carr (2014) refer to this in the context of teaching as:

A practical enterprise (that) seems to require flexible and adaptable context-sensitive judgement in complex and ever-changing circumstances, it would also appear to defy reduction to any simple or unexceptionable set of rules or prescriptions, or to the mastery of a pre-specifiable repertoire of technical competencies. (p. 96)

Cooke and Carr and many others draw on Aristotle’s notion of phrónêsis or practical wisdom as a model for effective teaching practice. Phrónêsis is considered a particularly apt concept as it suggests something more than cognitive meaning and practical “know-how” knowledge, referring to the achievement of a form of wisdom or a moral judgement where practice decisions take into account both facts and know-how, although these facts and know-how do not serve and cannot serve to determine the action or decision taken.

Aristotle distinguishes phrónêsis from two forms of knowledge he refers to as epistêmê and tékhnê. Epistêmê refers to what we today would call scientific knowledge; abstract, objective, context independent knowledge and empirical research can provide us with such knowledge. Tékhnê is practical knowledge, or craft knowledge that is practical and driven by conscious goals. In contrast, phrónêsis comprises a form of knowledge that involves value judgements based on reflection and on experience. It does not exclude knowledge of any sort but seeks to ensure that knowledge should be applied for the “good”. Referring to “the good” (or “the virtuous”) implies such decisions are value based and incorporate the emotions or (in Aristotelean terms) “the Passions”. The terms “emotions” and “values” are often seen by practitioners to be avoided as they are said to lead one away from objective research-based judgements. But phrónêsis does not exclude either epistêmê or tékhnê or theoretical and practical knowledge though they are distinct.

To act with practical wisdom (phrónêsis) in a specific clinical and professional practice context implies that the competent practitioner will be aware of and sensitive to the specific morals and needs of the situation and will act in accordance with what is good, decent and fair for the client or patient for their “wellbeing”. Such judgement cannot be constrained by any set of abstract principles or codified rules, or even guidelines, because such rules/laws/guidelines cannot determine their own application to specific situations. “You cannot remove the agency of the professional to a passive application of universal (abstract) principles to particular circumstances … judgement is required” (Abizadeh, 2002, p. 270). Judgement or professional decision making in specific circumstances however will require the guidance of the research evidence (evidence-based practice), although this information (or data) cannot determine or provide all the information for decisions that have to be made in that specific situation. Scientific findings, laws or guidelines do not provide sufficient information for decisions in relation to how they are to be applied.

It is not the intention of this chapter to go into the details and debates around Aristotle’s notion of phrónêsis. My goal is to suggest that it is crucial to professional practice. The important features of phrónêsis for the purposes of this chapter are:

  1. It is a form of practical knowledge that includes both theoretical and practical skills and knowledge but is not reducible to any of these.
  2. Essentially it is a form of knowledge that is achieved by individuals through experience with others, not through formal teaching.
  3. Phrónêsis for Aristotle was a moral virtue involving value judgements that include a “passionate element” or the emotions. Abizadeh (2002) argues that Aristotle’s answer to “What is the written law lacking that renders it insensitive to the particular circumstances?” is that, It is lacking “the passionate element” which “is not present in law but every human soul necessarily has it” (p. 271).
  4. phrónêsis involves real life context-dependent decisions in circumstances where guidelines or a set of principles are insufficient to guide such decisions.
  5. This chapter will argue that accounts of phrónêsis as “individualistic” or presented as personal achievements are limited and that to understand the process of the acquisition of wisdom it must be placed in a broader social perspective or context. This point will be addressed later in the chapter.

If, as I argue, a set of guidelines or rules cannot replace the value considerations of practical wisdom, what is it in professional practice that has in fact historically led, at best, to the downgrading, and at worst, to the ignoring of the role of wisdom in decision making? I propose that what has replaced, or at least downgraded, the role of practical wisdom is a newly emerging practice that assumes that such judgements are subjective and thus invalid or unscientific. I refer here to Evidence-Based Practice that prioritises the role of empirical research in professional practice. There has been an almost universal call from many professionals to become evidence based. What this means for practice and clinical decisions is explored next.

Evidence-Based Practice as the Basis for Professional Action and Decision Making

The notion of practical wisdom has not been a major focus of practice in healthcare or clinical education and in recent decades a movement has emerged towards objective empirically-based research driving decisions under the name of evidence-based practice (EBP). Tyreman (2000) argues that, in the case of modern medical teaching and practice, the main focus has been on technical instrumental practice rather than practical wisdom; “issues of uncertainty and under-determination as facts of life in clinical decision-making remain major challenges for the novice practitioner and medical teacher” (p. 119).

EBP had its origins in medicine (known as evidence-based medicine [EBM]) where it rapidly became the major paradigm for clinical practice and clinical decision making. It has rapidly spread among many other health professions such as physiotherapy, dentistry, nursing, occupational therapy and social work and, more recently, to many other non-health areas such as management. Biesta (2007) argues that EBP is a notion of professional action as intervention, and looks, “to research for evidence about the effectiveness of interventions. Research needs to find out, in other words, ‘what works,’ and the main if not the only way of doing this, so it is often argued, is through experimental research, most notably in the form of randomized controlled trials (RCT) seen by many EBP advocates as the ‘Gold Standard’ of research” (Biesta, 2007, p. 7).

Thus, EBP is an interventionist model that is basically concerned with the effectiveness of certain actions and procedures. In medical practice one can understand the relevance of this since the concern is whether certain practices work. An RCT can show in broad or macro terms, for example, what drug or procedure may “work” and what may not for certain medically diagnosed issues. In the health sciences EBP is seen as providing incontrovertible objective data on effective practice. In this view it is a more effective way of informing clinical action and decision making replacing entrenched practices based on outmoded traditions and unsupported subjective “unscientific” opinion. There is an implicit view within EBP that clinical decision making and action should be clearly supported and backed by research evidence (of a certain kind at that) and that personal experience or subjective judgement should play no major part in the action taken.

At one extreme, there are those who think that research will be able to give us ‘the truth,’ that ‘the truth’ can be translated into rules for action, and that the only thing practitioners need to do is to follow these rules without any further reflection on or consideration of the concrete situation they are in. (Biesta, 2007, p. 12)

According to Clegg (2005) the practice of giving priority to RCTs is as follows:

The epistemological argument at the centre of the evidence-based practice debate relates to the practice in systematic review of giving precedence to data from experimenter-manipulated controlled (preferably with random assignment) trials. While there are systematic reviews that include other sorts of data, as Davies (2000) points out, the idea of meta-ethnography sits uneasily with the form of the cumulative generalisation assumed by the argument for ‘evidence’ in systematic reviews. The power of (intervention) as opposed to natural variation, is both compelling and simple. By assigning control conditions to an intervention, and focusing on clear outcome measures, it is possible to make the argument that it is the intervention, not other causal factors, that is producing the desired effect. (p. 419)

There are, of course, more nuanced notions of EBP where practitioner experience is not relegated to mere opinion but is said to be a factor to take into account along with EBP in professional decision making. The question that arises is the nature of that interaction. The research evidence will provide information on what has worked in a specific experimental situation or (if qualitative research is providing the information) in specific contexts but cannot provide solutions to, or rules for, the specific situation in which the professional is actually working. The practitioner has to make decisions for the client or patient they are currently working with and the question is what is the basis for that decision? Even in medical practice, for example, best practice may not always mean simply adopting the drug or practice that is shown to be the most effective but using what is best for a specific client, taking into account their wishes.

The technical instrumental evidence-based focus of professional practice has been questioned by a number of writers in the arena of education. In Australian higher education, an academic and practice field known as ALL (Academic Language and Learning), also known as Academic Skills Advising, Language and Learning Development and Student Support, are areas of research that are “…basically concerned with assisting students with language and learning required at university” (Chahal, 2017, p. 2). The ALL Association journal Academic Language and Learning contains numerous papers on teaching, learning, evaluation and teaching methods among other diverse topics. EBP is the underlying discourse of the ALL journal with emphasis on EBP for all learning and teaching practices and outcomes. The ALL emphasis on EBP is an example of a now universally accepted approach in education and also health science professions that emphasises that professional decisions and practices should be based only on “scientific research”. The emphasis is on “… scientific research, evaluation and statistics [that] along with performance data constitute the empirical evidence used to inform decisions” (The US Institute of Educational Sciences, in Chahal, 2017, p. 5).

This assertion seems to ignore the practical or experiential knowledge of the practitioner who has to make decisions in specific situations. What it particularly ignores is that even though the experimental data provides information on “what works” or the most effective action to achieve a particular end this may not be the best solution to the particular client’s situation and a professional practitioner may consider another course of action more appropriate. As Biesta (2007) argues, the most effective practice (to achieve a specified end goal) may not be either a moral or a wise way of acting. Thus the argument here is that evidence, such as that from systematic reviews, can serve as a useful tool for professional practice. However, it is a tool and has to be recognised and used as a tool and does not in itself provide the information necessary for its translation into professional practice. Professional work is holistic and involves interactions with others and the situation or environment in which the work is taking place.

As pointed out by Biesta (2007), much of the work on EBP is implicitly dualistic in that it makes a distinction between the knower and the known with the knower seen as a passive onlooker in relation to the external world. However, a non-dualistic view (Biesta refers to John Dewey’s work) conceives of individuals as always in an organic relation to the external world that is altered by an individual’s actions and those changes feed back to the individual. This is a continuous circle of action reaction. The professional worker interacts with clients/students/patients and other professional workers and is changed by those interactions. The experienced practitioner is aware of the impact of these changes on their own actions, which include the actions and interactions with involved others. This includes tacit “know-how” based on their experience including the input from other professionals and also an understanding of the client’s wishes and needs. In short, the professional worker gains practical wisdom as a result of their interactions with others and the external world. This raises questions about the education of professional practitioners. It has already been noted that an essential aspect of such practice is practical wisdom that can’t be taught as a set of skills. In the section that follows I want to discuss an interactive notion of professional wisdom and how it may be gained. In doing this I will draw on the work of the Russian philosopher/psychologist Vygotsky with particular reference to his notion of the Zone of Proximal Development (referred to in the literature as the ZPD). But first some details on Vygotsky.

Vygotsky

Lev Semovich Vygotsky (1896–1934) was a Russian psychologist whose work within a short life left an impressive body of work that has to this day had a significant influence on psychology, education, linguistics, philosophy and many other areas. Vygotsky entered the field of psychology without any formal training in psychology; he graduated in law from Moscow University in 1917 with a background in the humanities in literature, art and philosophy. That year (1917) marked the beginning of the Russian Marxist revolution and the beginning of a period of revolutionary change in all areas of Soviet culture with a motivation to overthrow all those approaches that were based on non-materialist ideals. The task they set themselves was enormous, covering all areas of society including, particularly, education. The situation at that time was that of mass illiteracy with millions of people without any basic education at all. Thus, the reform of the educational system, the development of learning in schools and science in higher learning were critical priorities.

It was not until the early 1920s that Vygotsky entered the field of psychology with a doctorate in the Psychology of Art, an area not at that time seen as a standard psychology thesis. His formal entry into psychology began in 1924 after giving what was regarded as an impressive paper at the All Russian Psychoneurological Congress. As a result he was invited by the Director of the Moscow Psychological Institute K. N. Kornilov to become a member of that institute, thus launching his career in psychology (see Kozulin et al., 2003).

The institute where Vygotsky began his work in psychology was committed to creating a new approach in psychology based on Marxism or Dialectical Materialism. The institute’s program was to develop new and fresh approaches to psychology in a period of immense change in Soviet society. A significant goal in this was the application of psychology to educational processes relating to the goal of the education of millions of hitherto totally illiterate masses of people, many of them serfs under the old Czarist regime. It was an immense challenge though resources were made available and new forms of studying psychological processes were encouraged (see Cole & Scribner, 1978).

Vygotsky, though knowledgeable in all areas of Marxist thought, especially the work of Engels and Marx himself, became familiar with the work of many Western thinkers including Freud, Piaget, the American pragmatists G. H. Mead, John Dewey and William James, and the early behaviourists J. B. Watson and E. L. Thorndike. He was also familiar with the work of well-known Soviet psychologists such as I. P. Pavlov and V. N. Bekhterev whose work on classical conditioning and reflexology respectively had dominated psychology in Russia. His theoretical work shows the influence of all these important figures and through a critique of their work he was able to formulate his own unique sociocultural position.

Though Vygotsky’s work was broad and covered many areas, it was in the study of the development of consciousness or the higher mental processes in children that was unique and for which he was to be best known. His goal was to show the role of language (or signs) and tools as mediators in the development of the higher mental processes by which he meant the development of skills, of thinking and of external action. Vygotsky’s approach to this development was influenced by Piaget’s (and Freud’s) developmental or genetic method and Marx’s and Engel’s notion of the mediating function of tool use as a means of enhancing the performing of physical tasks not able to be carried out without that tool. There is an interaction between tool and sign in adults: a tool is a physical object used to make changes in the external environment, a sign serves an internal means of using that tool. The process of the development of a child’s cognitive ability and physical skills involves initial interactions with others, more competent others, who assist the child to perform tasks they are not able to undertake without such assistance. Eventually the child becomes able to perform that task without such assistance and, in Vygotsky’s terms, the task is internalised as a sort of locus of internal control of one’s actions. “The mastering of nature and the mastering of behaviour are mutually linked, just as man’s alteration of nature alters man’s own nature” (Vygotsky, 1978a, p. 55, see also pp. 52–57).

To further explain Vygotsky’s notion of the mediated development of higher mental functions I will take a small diversion here and refer to an everyday example of such mediation that Vygotsky himself used. The example is of the development of pointing in a young child. Initially the child may begin with an action of seeking to unsuccessfully grasp some object in her environment that is out of her reach. Her hand remains, fingers grasping, poised in the air. Her mother comes to the rescue realising that the child wants something and gives it to her. For the mother, the child is pointing that she wants some object and she is given that object. This fundamentally changes the situation for the child as she has achieved her goal by the action of another person. Vygotsky says “The child’s unsuccessful attempt engenders a reaction not from the object … but from another person” (Vygotsky, 1978b, p. 26). The meaning of the action is established by others and it is only later that the child understands that her action is one of pointing. The child’s action only becomes a meaningful gesture when others understand that the child is pointing. Vygotsky refers to this series of transformations as “internalisation”; “the interpersonal process is transformed into an intrapersonal one” (Vygotsky, 1978a, p. 57).

This seemingly quite simple description of the acquisition of a social gesture is more complicated than it appears. Eun, Knotek, and Heining-Boyn (2008) make the point that “a major characteristic of Vygotsky’s writings stems from the fact that Vygotsky was rooted in the traditions of high-context cultures. Writers within this tradition often omit or do not elaborate on concepts that are self-evident to them” (p. 134). His contemporary readers would understand that this was not a one-sided interaction between mother, or more competent other, with the child who is a passive recipient of input from a more powerful other. The child even at a young age is not a passive recipient of his mother’s input but is actively engaging her. For Vygotsky, the child is reality oriented and seeks to continually adjust herself to the surrounding environment; this is understood as making adaptations to the social or cultural environment. Pointing is not simply a natural action but a cultural one since the child learns to use a symbolic gesture to achieve a goal by means of another individual.

The example from Vygotsky illustrates his notion of the social (and we may add the cultural) origins of thought (and values and language). This principle of development, initially by means of cooperation with other more competent individuals, was incorporated into Vygotsky’s notion of the Zone of Proximal Development. Vygotsky proposed that children in working with others on tasks can perform at a higher level than if they were undertaking that task on their own. In a social interaction, the more competent others compensate for the lack of biological or neurological development and extend the child’s performance beyond this natural level: “They extend the child’s memory beyond the biological dimensions of the human nervous system and permit it to incorporate artificial, or self-generated stimuli, which we call signs” (Vygotsky, 1978a, p. 39). The “internalisation” of those signs changes the psychological structure of memory eventually enabling the child to direct its own behaviour without assistance.

Vygotsky’s ZPD, in its original form as indicated with the example of mother and child, was seen by him as a natural process of enculturation. The mother and the child would not have been fully cognisant of the impact of their actions though the outcome was a fundamental change in the cognitive structure of the child (and the mother). However, this natural process has provided a valuable tool or method for teaching and learning and it has been extensively adopted and adapted by educators and psychologists in many countries and different cultures up to the present time.

The ZPD has been extended to cover moral education (Balakrishnan & Narvaez, 2016), language learning (Maftoon & Sabah, 2012), second language learning (Shabani, 2016), primary healthcare (Hopwood, 2015) and creativity and the arts (Connery, John-Steiner, & Marjanovic-Shane, 2018) in adults and children. Some writers have also emphasised the role of the emotions (which they argue is implicitly held by Vygotsky himself) as a crucial aspect of the ZPD; “Thus, the dynamic process of establishing and maintaining the ZPD is successful only when emotionally laden reciprocal relations between the learner and the instructor allow for participants’ comfort and trust, which are manifested in constant negotiation of the subject of inquiry and the way it is presented and acquired” (Levykh, 2008, p. 97).

It thus is now accepted by many Vygotskian experts that the ZPD need not be limited to child learning practice nor to the acquisition of practical or conceptual skills. It has been shown to be a useful tool for understanding the process of learning in adults and in the internalisation of values (Franklin, 2014). The ZPD occurs in a cultural and emotive context as it is implied by Vygotsky that such advancements in learning imply a set of values shared by the learner and the more competent peer or teacher: “The very process of internalization from social speech (speech for others) to ego-centric speech, and then to inner speech (speech for oneself), is not merely emotionally laden, but originates in human emotions and desires” (Levykh, 2008, 96). A more recent interpretation of Vygotsky’s ZPD by Roth and Radford (2010) argues that:

conceptualizing the zone of proximal development in the manner we suggest here rests on a non-transmissive form of knowing and on a non-individualistic conception of the participants. As to the former, knowing is not theorized as the reception of already-made pieces of cultural-historical knowledge. Knowing refers rather to the possibilities that become available to the participants for thinking, reflecting, arguing, and acting in a certain historically contingent cultural practice. (p. 10)

In an analysis of a teacher/student-based interaction in a second grade mathematics classroom based on the ZPD approach, Roth and Radford (2010) developed an interpretation of the nature of the interaction that supports a non-individualistic interaction: “Our analysis shows that far from exhibiting an asymmetry, the zone of proximal development is an interactional achievement that allows all participants to become teachers and learners” (p. 303). In the ZPD situation they argue that teacher and student are already in a context where they share a common cultural/language background that enables that interaction. The teacher may be the competent participant and the students the learners, but the teacher can learn also from the interaction. She may realise that certain strategies she uses do not work so she adjusts her approach to that of the student who also positions herself to become receptive to the teacher. In the ZPD it is not a matter of a competent other simply correcting a less competent other who serves as some sort of sponge who absorbs already preconceived knowledge, but an interaction occurs that achieves a common conceptual ground; this is how learning occurs in the ZPD. The knowledge or skills achieved by the interaction constitutes new learning for all participants.

This “new learning” is not to be conceived as the acquisition by just one party of what may be referred to only as the learning of already established objective knowledge or as a learned skill but as a new understanding of the task at hand. As Roth and Radford (2010) put it, “Within this context, we need to better understand how participants draw from those resources to position themselves in zones of proximal development and to tune to others in conceptual and affective layers to collectively reach interactional achievement” (p. 306). Through these means practical wisdom can be both developed and refined.

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Rodd Rothwell PhD

Faculty of Health Sciences

University of Sydney, Australia

Practice Wisdom

Values and Interpretations

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