(From the E-i-C: Here are links to the previous chapters in this series < Zone of Proximal Development> We need your help. Before we publish all of these chapters as an ebook, we want the health professions community to weigh in on the confusing, missing, and disputed sections of each chapter. Please include your comments at the bottom of the post. We will acknowledge your contribution in the forthcoming ebook.)
Authors: Eashwar Chandrasekaran; Alan Taylor; Jen Williams
Editor: Daniel W. Robinson, MD
|What is your Educational Theory?|
|Name of Theory:
Transformative Learning Theory
|Main Authors or Originators:
Jack Mezirow, an American sociologist, died at the age of 91 (1923 – September 24, 2004). He transformed the field of adult learning and was a Professor Emeritus at Teachers College at Columbia University.
Robert Boyd, an American anthropologist, and Gordon Myers expounded on Mezirow’s understanding of transformative learning of ways to integrate the old and the new. Furthermore, Boyd and Myers furthered the field by placing the emphasis on logical reasoning, creating a new definition of transformative learning that is grounded more in logic and rational thinking.
|Part 1: The Hook|
|Mark, a first-year Emergency Medicine resident, hurries to room three as EMS brings in a patient, Joe, who is familiar to the ED. Mark and other residents routinely become frustrated with Joe, who comes to the ED monthly, at the very least, for recurrent exacerbations of his congestive heart failure and acute pulmonary edema. Numerous ED visits he has presented with severe acute respiratory distress due to poor compliance with his CHF and antihypertensive medications. His systolic blood pressures measured in the ED are rarely below 200 mmHg. Today his blood pressure is 211/104, has an O2 saturation of 83% on 4L nasal cannula of O2, and he has notable bilateral rales with significant lower extremity edema. Today, Mark again notes on his review of symptoms that he has worsening acute dyspnea, three pillow orthopnea, paroxysmal nocturnal dyspnea, a nonproductive cough, worsening bilateral lower extremity, and scrotal edema. When asked about his medication compliance, the patient states that he, as usual, has not been compliant with his regular medications, including his furosemide or antihypertensives. Mark promptly places Joe on BiPAP and initiates treatment with intravenous furosemide and nitroglycerin. After several minutes, and repeat assessments, Joe’s symptoms improve and he visibly begins to look better. Mark, feeling more comfortable with the patient’s medical stabilization, chastises Joe for, yet again, not following the recommended care by his treating physicians and failing to take his prescribed medications. Mark, visibly frustrated, abruptly storms out of the room and begins preparation to admit the patient to the medicine service.
As Mark sits down at the computer to chart, he begins a lengthy rant directed towards his fellow residents and the attending physician about his frustration with the overwhelming noncompliance and gross incompetence of Joe, as well as the vast majority of his patients. He argues that none of the patients seem to care at all about their health and that his attempts as a physician are meaningless if nobody wants to take ownership of their health. Mark describes the ED patients as lazy, irresponsible, and stubborn people who all have a plan to make his shift as aggravating as possible. As Mark’s attending physician listens to his ongoing, at times paranoid rant, she contemplates how to best address Mark’s comments, as she understands that his view of his patients is jaded and narrow. Besides, she knows that if she does not address his frustrations, he will have a higher chance of experiencing ‘burn-out.’ She recalls learning about Mezirow’s transformative learning theory when she participated in a faculty development course and decided to take that strategy in helping Mark to understand Joe’s situation in an effective manner.
|Part 2: The Meat|
|Overview of this theory
Jack Mezirow, an American sociologist, developed Transformative Learning with the intention of creating a theory comprising “a comprehensive and complex description of how learners construe, validate, and reformulate the meaning of their experience.”1 To do this, Mezirow argued that learners “must engage in critical reflection on their experiences, which in turn leads to a perspective transformation.”2
Mezirow describes transformative learning as having the following phases:3
1. Disorienting dilemma
2. Self-examination with emotions
3. Assessment of one’s assumptions
4. Relating one’s discontent and process of transformation are shared
5. Exploring options of new behavior
6. Planning a course of action
7. Finding knowledge and skills to implement plans
8. Experimenting with new roles
9. Building confidence and competence in using new roles and relationships
10. Reintegration into one’s life with the new perspective
Mezirow theorized that transformative learning would primarily be a conduit to developing independent thinking. He believed that a ‘disorienting dilemma’ essentially triggered a life crisis or major life transition that changes a person’s frame of reference by making the person reflect critically on his or her assumptions and beliefs thereby consciously creating and subsequently implementing plans that that will eventually resolve the original dilemma.2 Thus, in comparison to traditional adult education, wherein an uncritically assimilated explanation by an authority figure would suffice, transformative learning allows the student to make his or her interpretations rather than act on the purposes, beliefs, judgments or feelings of others.4
|Background about this theory
Jack Mezirow introduced the concept of Transformative Learning in a study based on 83 women returning to college in 12 different reentry programs. From this information, he developed the 10 phases described above, which reflect a process of personal perspective transformation.5 Since that time, the concept of Transformative Learning has been a topic of continued theory development and research as a subset of adult learning. Adult learns are self-directed, have learner control (organizing and managing learning in formal education settings), autonomy, ability to self-manage, and are autodidacts (able to pursue learning in a natural environment).6 In its essence, transformative learning theory represents an example of a constructivist approach to adult education, i.e., learning is contextual. Learners do not learn isolated facts and theories in an abstract, separate world apart from the real world. Instead, we learn in relation to what we know, what we believe, our prejudices, and our fears. Thus, we develop or construct personal meaning from our experiences and validate it through interaction and communication with others.7
Mezirow advocated that the goal of adult education and transformative learning is “to help adult learners become more critically reflective, participate more fully and freely in rational discourse and action, and advance developmentally by moving toward meaning perspectives that are more inclusive, discriminating, permeable, and integrative of experience.”2 To understand how individuals find meaning in the events they encounter, we must understand how people view the world and their experiences. Mezirow stated that we see the world through a web of assumptions and expectations described as a frame of reference. These assumptions play an influential role in actions by filtering and directing attention, guiding choices and interpreting the meaning of experience.8 Ultimately, these assumptions can contribute to prejudices, stereotypes, and unquestioned or unexamined beliefs that can create limitations and form subconscious barriers that we are unable to overcome.9
The 10 phases of the transformative process detailed above are not necessarily sequential, but generally, begin with a “disorienting dilemma” and conclude with a “changed self-incept that enables a reintegration into one’s life context.”2 The triggering event may be a single dramatic event, or a series of almost unnoticed cumulative events, a deliberate, conscious effort to make a change in one’s life, or a natural developmental progression.9 Mezirow asserted that reflection is an essential component of transformative learning, along with the ability to exercise reflective judgment by asking the following questions:
a. What exactly is the problem?
b. Was something missed in the original assumption of the course of action?
c. Why is this important?
By reflecting on these questions, and analyzing the fundamental assumptions applied to a given situation, the student develops the potential to lead transformation away from the habit.
|Modern takes or advances in this theory
Understanding the role of implicit memory, or the role of habits and attitudes emerging from unconscious thoughts or actions is paramount to determining whether disorienting dilemmas and the subsequent journey of recovery that follows is consistent with the practice of rational thinking. Some have insisted that this should form the basis of understanding our prior perceptions and their development in the first place.
Robert Boyd, an American anthropologist, has asserted that transformation is a “fundamental change in one’s personality involving the resolution of a personal dilemma and the expansion of consciousness resulting in greater personality integration.”10 Boyd expounded on Mezirow’s definition of transformative learning to suggest the disorienting dilemma behooves an individual to realize that old patterns or ways of perceiving are no longer relevant, to move to adopt new ways of seeing the situation and finding ways to integrate old and new models.11 Furthermore, Boyd and Myers assert that unlike Mezirow, who considers ego as central in the process of perspective transformation, the emphasis should be placed on reason and logic, thus creating a definition of transformative learning that is grounded more in logic and rational thinking. In this approach, the emphasis is more on understanding the steps one took to realize the transformation which occurred and less on pure self-reflection. This also relates to other views of transformative theory in which the ego or self is not necessarily the sole locus of learning, instead, reason in the process of attaining transformation is more important than the change elicited within an individual.
It is often difficult to find where the definition of transformative learning finds its boundaries with other concepts of constructivist thinking, such as critical thinking or meaning-making. Constructivists advocate that the learner forms knowledge by constructing meaning through critical reflection on the learners’ assumptions. Transformative learning uses this concept of self-reflection, but also involves a critical change that alters assumptions and reintegrates successfully into the learner’s new, broadened horizon.12
|Other examples of where this theory might apply in both the classroom & clinical setting
When reflecting on how resident physicians gain knowledge, this is precisely learner-specific. Some residents may learn best from role modeling behavior of their attending physicians (social learning theory). Others may find more significant benefit from time spent with self-directing learning using a technology-based platform.13 Regardless of the method of knowledge inquiry and mastery in residency, the experience of critical incidents, such as an adverse outcome, or a memorable patient encounter, is familiar to most residents. These events can have a profound effect on learning, arguably underpinned by transformative learning theory. In these situations, the adverse outcome is synonymous with the “disorienting dilemma” that acts as the catalyst for the change in attitude or perspective described in Mezirow’s transformative learning theory. Often in residency curricula, these critical events are further evaluated via formalized reflective writing and communication opportunities. The traditional format of mortality and morbidity meetings and associated didactic education sessions often focuses on how a given adverse event could have been approached differently for an improved outcome. This reflection affords the opportunity to teach how to optimize practice patterns and approaches for residents who find themselves in similar clinical situations in future. Similarly, in professional practice settings, quality improvement initiatives often are motivated by critical events. For example, an adverse event related to failed airway management during procedural sedation may subsequently result in the development of quality improvement initiatives (such as procedural sedation checklists) aimed at reducing or preventing the occurrence of any future similar adverse events.
|Annotated Bibliography of Key Papers on this theory
Torre, D. (2006). “Overview of Current Learning Theories for Medical Educators.” American Journal of Medicine 119(10): 903-907.
As a first foray into educational theory, an overview of the broad categories and subgroups is useful.13 This piece provides the medical educator with an easily digestible, well-summarized, a taste of relevant theories pertaining specifically to medical education. Its benefit and limitation are the same – brevity. Barely scraping the surface of the array of adult learning theories means that reading this article in isolation is unlikely to suffice for a clear understanding of any one of the theories in depth. However, with its broad remit covering learning theories, in general, comes a good foundation on which to build a more thorough understanding of any individual learning theory. This article is a sensible place to start for the novice medical educator who is new to the scholarship of teaching and learning and as yet unfamiliar with the concepts and vocabulary of educational learning theories.
Mezirow, J. (1978). “Perspective Transformation.” Adult Education 28(2): 100-110.
Perspective Transformation is an historical article by Jack Mezirow himself (the creator of Transformative Learning Theory).14 He references women’s rights and the United States civil rights movement, Friere, Marx and even the Greek king Sisyphus in describing a multitude of evidence for changing perspectives within education and society. Readers will delight at discovering Jack Mezirow’s insights as they were at the very genesis of his Transformative Learning Theory and will find a variety of tangible examples of its pervasion through many aspects of society. Mezirow relates transformation and learning to adult development, pointing out that education involves more than merely the acquisition of knowledge. He advocates strongly for a critical assessment of the cultural and psychological assumptions we live within so that we might transform our perspective and undergo self-development.
Kitchenham, A. (2008). “The Evolution of John Mezirow’s Transformative Learning Theory.” Journal of Transformative Education 6: 104-123.
The Evolution of Jack Mezirow’s Transformative Learning Theory provides a thorough review of Mezirow’s publications, affording the reader a clear understanding of the developmental timeline of this theory.15 It explains the genesis of the argument (Habermas’ three domains of learning) and describes the stepwise progress from the initially proposed ten phases through later revision and the inclusion of social aspects to the more recent expansion concerning constructivist theory, psychic distortion, schema therapy and individuation. Not only does this paper allow the reader to understand in depth Transformative Learning Theory, but also it provides an exciting example of how a learning theory develops from inception, through a process of modification, expansion, and refinement into a sound theory referencing concrete examples from modern adult learning settings.
Taylor, E. (2000). “Fostering Mezirow’s transformative learning theory in the adult education classroom: a critical review.” The Canadian Journal for the Study of Adult Education 14(2): 1-28.
This article interrogates the literature for evidence of the integration of transformative learning theory practices within adult education.16 A variety of findings on the relationship between critical reflection and affective learning are discussed, with examples cited from multiple pieces of literature. The primary assertion and a vital component of Mezirow’s theory is the association between heightened emotions and more effective critical reflection. This paper provides the reader with some fundamental questions to pose when preparing to embed this theory within teaching practices and provides empirical examples of the theory’s practical utilization in the classroom. There is an emphasis on discourse, and favoring of the importance of affective learning over critical reflection – almost suggesting that emotional experience in and of itself is enough to trigger a change in perspective within the learner, even without associated deliberate reflection. Perhaps subconscious reflection follows emotional events?
Cranton, P. (2016). Understanding and Promoting Transformative Learning: A Guide for Educators of Adults. San Francisco, John Wiley & Sons, Inc.
Cranton provides a deep dive into Transformative Learning from an adult learning viewpoint.17 Her lengthy work describes the theory, going on to demonstrate its position amongst other adult learning theories. It is an up-to-date synthesis of the research and application of Transformative Learning Theory across adult education in a variety of spheres. This work is best read over several sessions, allowing the reader to synthesize the significant body of information contained within. For the educator, this book provides some useful guidance on creating a classroom environment within which the practical manifestations of Transformative Learning Theory can flourish. Cranton advocates for maintenance of a safe learning environment, where non-judgemental techniques can foster self-reflection. The clinical educator readership will undoubtedly find some similarities between these recommendations and those promoted by Rudolf in the specific area of clinical simulation. Educators are assisted to “get meta” by the provision of a chapter on Transformative Learning Theory from the educator’s (as opposed to the learner’s) perspective. They also “get meta” with a series of crucial self-reflective questions with the aim to develop a critical analysis of one’s teaching strategy within the educator him/herself.
|Limitations of this theory
There are multiple criticisms of Transformative Learning, as with many other theories. The main criticism stems from the importance Mezirow places on rational thought. Some suggest that Mezirow places too much emphasis on the rational reflection.18
|Part 3: The Denouement|
|The following day after the resident conference, Mark’s attending physician pulls him aside and asks him to follow her. She cryptically leads him to the 6th floor of the medical wards, and into a patient room. Mark quickly notices that Joe is in the room, his patient from the day prior. After the brief round of formalities, his attending clarifies the motivation for their field trip. She asks Mark to listen, prompting Joe to begin a winding story of his life. Joe informs Mark that he was previously employed on an oil rig when he lived in Louisiana, but had suffered a debilitating injury that left him unable to work in that field. He then struggled to find further employment that provided sufficient payment to pay his bills and left him without medical insurance. His wife took on an extra job, but she suffered a massive stroke shortly afterward, racking up massive medical bills, and rendering her unable to work. Also, Joe’s wife developed an infected sacral decubitus ulcer requiring surgical debridement, further worsening their debt. Due to his wife’s disability and inability to find home care for her, Joe was unable to hold a stable job, exacerbating this vicious cycle. In doing so, his health began to fail as well, as he was unable to afford his antihypertensive medicines, and subsequently developed heart failure, further requiring additional medications. As bills piled up, Joe was forced to sell his car, and he and his debilitated wife find it necessary to move out of their house into an apartment on the far side of town, several miles away from the free clinic and far from the bus route. Also, the lengthy wait at the clinic and the time required to make the trip across town and back would need Joe to be away from his wife too long. Joe stated that when he was able to obtain a prescription for his medications that could treat his hypertension and CHF, he was forced to skip doses to make them last as long as possible. This practice, however, led to frequent CHF exacerbations leading to his ED visits and admissions.
Mark was dumbfounded. As he bathed in the painful words of Joe’s story, Mark was able to see through Joe’s eyes the difficulty in managing his chronic disease process, and the struggles that Joe and many other of his patients must face. No longer did these patients seem lazy or irresponsible. These were people that fell prey to the difficulties of life leading to their gradual downfall into a complicated healthcare process that did not seem to understand its patients. Mark absorbed these enlightened thoughts over several days and realized that he needed to make his other residents aware of what he appeared to have ignored to this point. He developed a planned lecture series geared toward fellow providers, involving videos of Joe and other patients weaving their narratives, with a plan to bring clarity to those same providers that care for them on a daily basis.
Please leave your peer review in the comments below
- Cranton P. Understanding and promoting transformative learning: A guide for educators of adults. San Francisco: Jossey-Bass; 1994.
- Mezirow J. Transformative dimensions of adult learning: ERIC; 1991.
- Nohl A-M. Typical phases of transformative learning: A practice-based model. Adult Education Quarterly. 2015;65(1):35-49.
- Mezirow J. Transformative learning: Theory to practice. New directions for adult and continuing education. 1997;1997(74):5-12.
- Mezirow J. Education for perspective transformation: Women’s reentry programs in community colleges. New York: Center for Adult Education, Teachers College, Columbia University; 1975.
- Candy PC. Self-Direction for Lifelong Learning. A Comprehensive Guide to Theory and Practice: ERIC; 1991.
- Cranton P. Professional Development as Transformative Learning. New Perspectives for Teachers of Adults. The Jossey-Bass Higher and Adult Education Series: ERIC; 1996.
- Mezirow J. Learning as Transformation: Critical Perspectives on a Theory in Progress. The Jossey-Bass Higher and Adult Education Series: ERIC; 2000.
- Cranton P. Understanding and promoting transformative learning: A guide for adult educators: San Francisco: Jossey-Bass; 2006.
- Dix M. The cognitive spectrum of transformative learning. Journal of Transformative Education. 2016;14(2):139-162.
- Boyd RD, Myers JG. Transformative education. International journal of lifelong education. 1988;7(4):261-284.
- Brookfield SD. Transformative learning as ideology critique. Learning as transformation: Critical perspectives on a theory in progress. 2000:125-148.
- Torre DM, Daley BJ, Sebastian JL, Elnicki DM. Overview of current learning theories for medical educators. The American journal of medicine. 2006;119(10):903-907.
- Mezirow J. Perspective transformation. Adult education. 1978;28(2):100-110.
- Kitchenham A. The evolution of John Mezirow’s transformative learning theory. Journal of transformative education. 2008;6(2):104-123.
- Taylor E. Fostering Mezirow’s transformative learning theory in the adult education classroom: A critical review. The Canadian journal for the study of adult education. 2000;14(2):1.
- Cranton P. Understanding and promoting transformative learning: A guide to theory and practice: Stylus Publishing, LLC; 2016.
- Taylor EW. The Theory and Practice of Transformative Learning: A Critical Review. Information Series No. 374. 1998.