Discuss nature of Therapeutic relationship

and client collaboration, therapeutic use of

self and collaboration, intentional
relationship model.
The Nature of the Therapeutic Relationship in Occupational
Therapy
• Occupational therapists carry the privilege and responsibility to
maintain the trust that clients and interprofessional colleagues place
in our ability to accompany people through their most difficult
periods of rehabilitation. The Occupational Therapy Practice
Framework emphasizes therapeutic use of self as “integral to the
practice of occupational therapy [and] used in all interactions with
clients.
• An effective therapeutic use of self requires the therapist to strive
toward a fundamental understanding of clients as human beings, at
an interpersonal level.
• Biopsychosocial Issues and Psychiatric Overlay

• Beyond the usual range of negative emotions that clients experience lies a
level of interpersonal complexity that is introduced by those with
psychiatric overlay or mental health diagnoses. It has been
estimated that roughly 15% to 39% of individuals with chronic illness or
impairments also have clinically significant psychiatric overlay.
• Depending on the diagnosis, psychiatric overlay can introduce a
host of challenges to the therapeutic relationship, ranging from behaviors
that are often labeled as “noncompliance” or “resistance” to manipulative
behaviors or excessive demands on the therapist’s time and energy.
• Background and Evidence Base
• As a well-established health care discipline, OT traditionally emphasizes the
value and importance of therapists’ interactions with their clients.
• One of the most common terms used to refer to therapist–client
interactions is the therapeutic relationship.
• Literature and dialogue about the therapeutic relationship commonly
address topics such as rapport building, communication, conflict
resolution, emotional sharing, collaboration, and partnership between
therapists and clients.
• Therapeutic use of self is a popular term used in OT to refer to the
therapists’ deliberate efforts to enhance their interactions with clients.
Therapeutic Use of Self and Collaboration
• Collaboration is a critical element in client-centered care.
Collaboration refers to the process of mutual participation on the part
of client and therapist. It also includes providing choice, involving
clients in decision making, and encouraging clients to actively
contribute and to set their own goals for therapy.
• One of the primary approaches to collaboration involves educating
clients about all aspects of the treatment process and providing them
with information about the purpose and relevance of any procedure
or treatment approach. Providing a rationale at each session increases
the likelihood of client involvement in therapy.
• The second most preferred approach involved collaborating with
clients by encouraging them to make more decisions during the
therapy process, by supporting their perspectives, by gathering
feedback from the client before selecting or recommending an
activity, and by asking the client to recommend his or her own goals
for therapy.
• Other approaches involving problem solving, empathizing, and
instructing clients were less frequently used. Interestingly, these
findings did not differ based on the age group of the clients being
treated.
The Intentional Relationship Model
• The IRM provides a practical skill set and an interpersonal reasoning
approach that presents different approaches to communication that are
necessary to sustain a positive working relationship with a client.
• According to IRM, it is the therapist’s responsibility to work to develop a
predictable and trusting relationship with the client irrespective of any
interpersonal difficulties or misgivings that the client may bring into the
therapy process.
• This does not assume that the therapist will always be successful at
building such a relationship. However, it does assume the therapist
recognizes it is his or her responsibility to establish and maintain this
relationship.
Client Interpersonal Characteristics
• Individuals react to chronic conditions with tremendous variability.
Recognizing and responding appropriately to psychological
heterogeneity within and between clients is vital to a successful
therapy outcome. Fear, anxiety, sadness, hopelessness, anger, and
rage are inevitable emotions that any client with a chronic condition
faces during the course of his or her experience.
• However, the duration and degree to which these emotions become
entrenched and affect overall psychological, interpersonal,
occupational, and health-related behavior and functioning vary
considerably within and between individuals.
• Communication style refers to a client’s ability to communicate in a
clear, well-paced, and detailed yet succinct manner that is appropriate
to his or her developmental level and cognitive ability.
• Response to change and challenge refers to a client’s ability to adapt
to changes in the therapy plan or environment and his or her
approach to OT tasks and situations that are new or challenging
• Affect defined as a client’s general emotional expression during
therapy, ranging from appropriately buoyant for the situation
(flexible) to flat to heightened.
• Predisposition to giving feedback involves a client’s ability to provide
the therapist with appropriate negative or positive comments about
his or her reactions to the therapist and experience of therapy as
either helpful or unhelpful.
• Orientation toward relating defines a client’s need for interpersonal
closeness versus professional distance within the therapeutic
relationship. Difficulties may occur when the client’s expectations
about the relationship differ from those of the therapist.
• Preference for touch involves a client’s observed comfort or
discomfort with or expressed reaction to any type of physical touch,
whether it be a necessary part of treatment or an expression of
caring.
The Inevitable Interpersonal Events of
Therapy
• Similar to client characteristics, uncomfortable or emotionally laden
situations that occur during therapy are a normal part of everyday
practice for the experienced therapist. However, knowing how to
anticipate and respond to them in a deliberate and therapeutic way is
not necessarily an assumed, universal skill.
• According to IRM, an interpersonal event is a naturally occurring
communication, reaction, process, task, or general circumstance that
occurs during therapy and that has the potential to fortify or weaken
the therapeutic relationship depending on how it is handled.
The Therapist’s Use of Self
• As defined the therapeutic use of self is the application of empathy and
intentionality to an interpersonal knowledge base and corresponding set of
communication skills that are applied thoughtfully to resolve evocative
interpersonal events in practice. A therapeutic mode is a specific way of relating
to a client. The IRM identifies six therapeutic modes:
• 1. Advocating
• 2. Collaborating
• 3. Empathizing
• 4. Encouraging
• 5. Instructing
• 6. Problem solving
• Advocating
• Ensuring that the client’s rights are enforced and resources are
secured; may require the therapist to serves a mediator, facilitator,
negotiator, enforcer, or other type of advocate with external persons
and agencies.
• Collaborating
• Expecting the client to be an active and equal participant in therapy;
ensuring choice, freedom, and autonomy to the greatest extent
possible.
• Empathizing
• Ongoing striving to understand the client’s thoughts, feelings, and
behaviors while suspending any judgment; ensuring that the client
verifies and experiences the therapist’s understanding as truthful and
Validating.
• Encouraging
• Seizing the opportunity to instill hope in a client. Celebrating a client’s
thinking or behavior through positive reinforcement; conveying an
attitude of joyfulness, playfulness, and confidence.
• Instructing
• Carefully structuring therapy activities and being explicit with clients
about the plan, sequence, and events of therapy. Providing clear
instruction and feedback about performance; setting limits on a
client’s requests or behavior.
• Problem solving
• Facilitating pragmatic thinking and solving dilemmas by outlining
choices, posing strategic questions, and providing opportunities for
comparative or analytical Thinking.
Interpersonal Reasoning
• An interpersonal reasoning process, described in the following
section, can be used to guide the therapist in deciding when a mode
shift might be required and determining which alternative mode to
select.
• Because the interpersonal aspects of OT practice are complex and
require a therapist to possess a highly adaptive therapeutic
personality, the IRM recommends that therapists learn to the
therapeutic modes in a flexible manner according to the different
interpersonal needs of each client and the unique demands of each
clinical situation.
• Anticipate
• Based on your observations, information from others who have had
experience with the client, and any experience you have had with the
client, anticipate the likely interpersonal events that may occur during
therapy and the modes that might work best.
• Determine if a mode shift is required
• Ask yourself the following questions to determine whether a mode
shift is required: What mode am I currently using with this client, if
any?
• Identify and cope
• Use Intentional Relationship Model language to label a difficult client
characteristic or interpersonal event when it occurs. Do what it takes
to collect yourself and get emotional perspective on the situation.
Remind yourself not to take it personally.
• Draw on any relevant interpersonal skills associated with the
mode(s)
• Think about other communication, rapport building, and/or conflict
resolution skills that you might draw upon in association with your
mode use.
• Gather feedback
• Gather nonverbal or verbal feedback from the client as to whether or
not he or she feels comfortable with the way you approached the
event or difficulty.
Conclusion
• we reviewed evidence that supports therapeutic use of self in OT. We
learned about the field’s emphasis on collaboration and about how
the IRM can support that emphasis. The IRM is a conceptual practice
model that explains how therapists can apply an interpersonal
reasoning process to understand and respond supportively to clients
in difficult or awkward moments.
• The model requires therapists to take responsibility for the emotional
well-being of their clients during the therapy interaction by
understanding the client’s unique interpersonal characteristics and
adjusting their therapeutic personalities accordingly.
References
• Willard & Spackman’s occupational therapy 13 Edition