1. Mirtha Montejo Whaley, PhD, MPH, OTR/L Assistant Professor and Director of Academic Affairs Entry Level Doctor of Occupational Therapy Program College of Health Care Sciences Nova Southeastern University, Tampa Catherine Peirce, PhD, OTR/L DrOT Program Director and Associate Professor Occupational Therapy Program College of Health Care Sciences Nova Southeastern University, Ft. Lauderdale

2. Course Objectives: At the completion of this course, participants will be able to: 1.Discuss the Occupational Therapy Practice Framework as a guiding document of practice, and it’s relationship to the therapeutic use of self. 2.Define therapeutic use of self and the intentional relationship and their application in the therapeutic relationship 3.Understand the emergence, decline, and re-emergence of therapeutic use of self in occupational therapy practice 4.Demonstrate an understanding of therapists’ interpersonal characteristics, and identify their own. 5.Demonstrate an understanding of clients’ characteristics 6.Discuss the difference between clients’ enduring, and situational characteristics that can affect the therapeutic relationship 7.Demonstrate an understanding of therapeutic modes 8.Describe and compare therapeutic modes and their application in practice 9.Apply the use of therapeutic use of self, to manage inevitable events of therapy 10.Articulate the benefits of incorporating therapeutic use of self to support the therapeutic relationship and improve outcomes of therapy 2

3. Therapeutic Use Of Self and The Intentional Relationship Case example of an interaction gone wrong After viewing the video, identify an example of an undisciplined response….a reaction Then identify an example of a disciplined response Nurse and angry patient 3:54 min https://www.youtube.com/watch?v=f4qCP_NEYYU 3(Source: Taylor, 2008)

4. In this next section, we will: Review Basic Concepts Update practitioners on recent changes Create a common language to facilitate communication during presentation So, we start with the Occupational Therapy Practice Framework (OTPF) 4

5. Therapeutic Use Of Self and The Intentional Relationship Occupational Therapy Practice Framework III (AOTA, 2014) now known as the Framework Defines occupational therapy as it applies to both occupational therapists and occupational therapy assistants Defines the domain of occupational therapy What we do, to whom, to what extent “Areas in which we have a body of knowledge and expertise” (AOTA, 2014) Describes the process of occupational therapy” Actions practitioners take when providing services, which are client- centered and focused on engagement in occupation (AOTA, 2014) AOTA, 2014 5

6. Therapeutic Use Of Self and The Intentional Relationship OTPF II (2008) Therapeutic use of self considered an intervention OTPF III (2014), now referred to as the Framework Therapeutic use of self considered “an essential part of the process of occupational therapy” While interventions may be selected and used at the discretion of the practitioner As an essential part of the process of OT, therapists are expected to apply the therapeutic use of self in all their client interactions 6(Source: Taylor, 2008)

7. Therapeutic Use Of Self and The Intentional Relationship Therapeutic Use of Self Origins in psychotherapy Not clearly conceptualized in OT for many years Definition has fluctuated, frequently in response to a changing practice paradigm at significant periods for OT practice (Taylor, 2008, p 46; Taylor, 2008, pp 3-8) 7

8. Therapeutic Use Of Self: Definitions In Occupational Therapy, therapeutic use of self has been defined in various ways. Punwar & Peloquin’s (2000)definition became part of the OTPF in 2002 (as cited in Taylor, 2008, p5) A practitioner’s planned use of his or her personality, insights, perceptions and judgments as part of the therapeutic process (Taylor, 2008) 8

9. Therapeutic Use Of Self: Definitions Mosey (1981) “The deliberate use of one’s responses as part of the therapy “(as cited in Taylor, 2008, p 5) Denton (1987)“…a way of communicating an attitude of respect and acceptance to clients” (as cited in Taylor, 2008, p 5) Hagedorn (1995)“The artful, selective, or intuitive use of personal attributes to enhance therapy” (as cited in Taylor, 2008, p 5) Cara & MacRae (1998) “Therapeutic use of self is developing an individual style that promotes change and growth in clients and helps furnish them with a corrective emotional experience” (as cited in Taylor, 2008, p 5) (Taylor, 2008, p 5) 9

10. Therapeutic Use Of Self and The Intentional Relationship The Framework (2014) identifies therapeutic use of self as part of the process of occupational therapy and further defines it as… An integral part of the occupational therapy process …which allows occupational therapy practitioners to develop and manage their therapeutic relationships with their clients by using narrative, clinical reasoning; empathy; and a client-centered, collaborative approach to service delivery (Taylor & Van Puymboeck, 2013, as cited in AOTA, 2014) 10

11. Therapeutic Use Of Self and The Intentional Relationship What the research evidence indicates Respondents to a national study of occupational therapists (N=568) (Taylor, Lee, Kielhofner, & Ketkar, 2007) 80% = most important determinant of the outcomes of therapy 50% = not prepared in professional program on TUS Participants felt insufficiently prepared to manage difficult interactions < 33 % felt there was enough knowledge in OT about the TUS 4% of participants had course dedicated to TUS Participants identified insufficient information in the OT literature on TUS (Taylor, 2008, p 3) 11

12. Therapeutic Use Of Self and The Intentional Relationship What the research evidence indicates (Cont.) OT studies by Ayres- Rosa & Hasselkus (1996), Cole and McLean (2003), identified the client-therapist relationship as key determinant of the outcomes of therapy (as cited in Taylor, 2008, p 3) Studies in psychology by Bergin & Garfield (1994), and Orlinsky (1994) (as cited in Taylor, 2008, p 3)found the variable most consistently associated with successful outcomes across different perspectives in psychotherapy was the therapeutic relationship (Taylor, 2008, p 3) 12

13. Therapeutic Use Of Self and The Intentional Relationship Therapeutic use of self, eras, and paradigms Era of moral treatment (Europe, 1700’s) Humanitarian Promoted self-determination through engagement in occupations of daily life Early occupational era (early 1900’s) Emphasis on crafts and activities Therapist as expert, role model for engagement in occupation Intent to inspire joy and confidence (Taylor, 2008, pp 4-5) 13

14. Therapeutic Use Of Self and The Intentional Relationship Therapeutic use of self, eras, and paradigms (Cont) Era of inner mechanisms (1940’s) Focus on medical model, “cure” Emphasis on pathology Focus on expertise Competence and professional attitude toward clients, favoring skills such as Tact, self-control, objectivity Good judgment Capacity to identify with client (Taylor, 2008, p 6) 14

15. Therapeutic Use Of Self and The Intentional Relationship Therapeutic use of self, eras, and paradigms (Cont) Activities used as mechanism to understand “inner motives” (client selection of activity; his/her performance; selection of materials, color, etc; degree of dependence on therapist were all ways to understand the client’s inner drives Most important was the relationship between the client and the therapist to help client achieve change, i.e. resolution of inner conflicts Competence and professional attitude toward clients, favoring skills such as Tact, self-control, objectivity Good judgment Capacity to identify with client (Taylor, 2008, p 6) 15

16. Therapeutic Use Of Self and The Intentional Relationship 16 Re-emergence of occupation (1960’s) Reilly and others note the profession has moved away from its roots Therapeutic relationship falls out of favor Move is toward engagement in occupation as the central focus of occupational therapy (Taylor, 2008, p 7)

17. Therapeutic Use Of Self and The Intentional Relationship Re-Emergence of the therapeutic relationship Current discussions acknowledge the importance of The client’s narrative An attitude of respect and trust Cultural competence (I prefer Dr. Roxie Black’s cultural effectiveness) A client-therapist relationship that is: Collaborative, where power doesn’t rest with the therapist Client-centered Built on caring and empathy Using narrative, clinical reasoning (Taylor, 2008, p 7) 17

18. Therapeutic Use Of Self and The Intentional Relationship Current views on the therapeutic relationship Important attributes and skills of the therapist Self-awareness Respond vs. react Recognize personal issues that may interfere with the therapeutic relationship Controlling/ correcting responses that may interfere with therapeutic responding (Taylor, 2008, p 10) 18

19. Therapeutic Use Of Self and The Intentional Relationship Current views on the therapeutic relationship (Cont.) A successful and positive therapeutic relationship is: Client-centered and collaborative Addresses power dynamics of the relationship Creates a level-playing field (no power-differential) Client is agent in his own process of therapy A successful and positive therapeutic relationship is based on: Caring and empathy Address affective aspects of the relationship Connects at emotional level (Taylor, 2008, p 10) 19

20. Therapeutic Use Of Self and The Intentional Relationship Current views on the therapeutic relationship (Cont.) A successful and positive therapeutic relationship utilizes: Clinical reasoning The client’s narrative To assist the therapist Reflect on aspects of the therapeutic encounter, including the client-therapist relationship, to understand assessment findings and engage in intervention planning 20(Source: Taylor, 2008)

21. Therapeutic Use Of Self in Psychotherapy (Taylor, 2008, p 46) 21 The Therapist The Client Interpersonal Relating

22. The Relationship In OT (Taylor, 2008, p 46) 22 The Client The Occupation Treatment approaches, activities, and strategies selected to improve performance Occupational Engagement (focus of occupational therapy interventions) Interpersonal Relating (reciprocal, between therapist and client) The Occupational Therapy Practitioner

23. A Model of the Intentional Relationship in Occupational Therapy ( Taylor, 2008, p 48) Client: The client brings intrinsic factors into the relationship which include his/her enduring characteristics. Situational characteristics will show up in response to specific situations In the process of this relationship and in the process of treatment, inevitable interpersonal events take place. Inevitable interpersonal events have the potential for destroying or strengthening the client-therapist relationship The client will have his or her own interpretation of and reaction to the event This Intentional Relationship Model inhabits the space where the therapist engages in Interpersonal Relating with the client It is the therapist’s responsibility to utilize therapeutic responding rather than reacting, to address the inevitable interpersonal event with the client. There is a process that occurs between the client and the therapist, and which Taylor labels the therapeutic relationship process. Note that the process is reciprocal Therapist: Brings her own personal factors, including her interpersonal knowledge base; his/her repertoire of therapeutic modes; And her knowledge base of interpersonal reasoning

24. Therapeutic Use Of Self and The Intentional Relationship Client interpersonal characteristics are emotional responses and reactions that are observable and that happen in the course of treatment Interpersonal characteristics fall into one of two categories Enduring interpersonal characteristics Situational interpersonal characteristics (Taylor, 20008) 24

25. Therapeutic Use Of Self and The Intentional Relationship Client interpersonal characteristics Enduring interpersonal characteristics Emotions, reactions, or behaviors that are lifelong patterns Reflect the client’s temperament and personality Will likely also reflect the client’s cultural characteristics Situational interpersonal characteristics Emotions, reactions, or behaviors that are situation-specific Are triggered by an event or occurrence in the health care environment Depart form the client’s usual patterns of responding and repertoire of behaviors Provoke a reaction in the therapist (sadness, worry, frustration) 25(Source: Taylor, 2008)

26. Therapeutic Use Of Self and The Intentional Relationship Enduring characteristics Communication style Spoken or signed language If therapist is unable to respond to client’s communication style, this has the potential to affect the quality of the therapeutic relationship Capacity for trust May be evident in both verbal and non-verbal communication Some clients “test” the therapist’s commitment to the client and the relationship 26(Source: Taylor, 2008)

27. Therapeutic Use Of Self and The Intentional Relationship Enduring characteristics (Cont.) Need for control May manifest as attempts to manipulate, influence, or dominate the therapeutic situation Capacity to assert needs Degree to which a client is able to request what he needs or wants May be in terms of challenges in therapy, type of response or feedback from the therapist If unable, therapist will not be able to fulfill the client’s needs Conversely, the client may be demanding in situations when he/she really does not require assistance or needs met 27(Source: Taylor, 2008)

28. Therapeutic Use Of Self and The Intentional Relationship Enduring characteristics (Cont.) Response to change and challenge Clients vary in their capacity to manage change Most clients will experience difficulty with change and challenges Affect Clients affective expressions vary as well Extreme changes, or displays of intense emotions may indicate the client has difficulty self-regulating, and may indicate more serious problems with the potential to disrupt the client’s treatment 28(Source: Taylor, 2008)

29. Therapeutic Use Of Self and The Intentional Relationship Enduring characteristics (Cont.) Predisposition to giving feedback Clients also vary in the degree of comfort providing feedback to the therapist Feedback may have to be solicited Even then may be veiled or difficult to understand Capacity to receive feedback Clients may have difficulty receiving negative feedback as well as positive Their reactions to the feedback can inform the therapist as to any difficulties in this area 29(Source: Taylor, 2008)

30. Therapeutic Use Of Self and The Intentional Relationship Enduring characteristics (Cont.) Response to human diversity This is a very personal area in response to gender, cultural, religious, political preferences, and other differences Clients may feel moved out of their comfort zone May become an issue between client and therapist Orientation toward relating Refers to the client’s “rules” in reference to relating; the expectations of reactions to self-disclosure, etc., 30(Source: Taylor, 2008)

31. Therapeutic Use Of Self and The Intentional Relationship Enduring characteristics (Cont.) Preference for touch Can affect therapeutic interventions that require touch and handling Can even affect how people respond to how they are approached (i.e. preference to not be approached from behind) 31(Source: Taylor, 2008)

32. Therapeutic Use Of Self and The Intentional Relationship Enduring characteristics (Cont.) Capacity for reciprocity Client may have difficulty relating in what would be considered psychologically healthy and developmentally appropriate manner May have limited capacity to demonstrate empathy, tolerance, or patience to the therapist May be unable to appreciate the therapist’s perspective if there should be a disagreement May be unable to express appreciation toward therapist 32(Source: Taylor, 2008)

33. Modes Advocating Protects client’s rights Connects with resources Collaborating Sees client as active participant Provides choices, supports autonomy Empathizing Non-judgmental Validating Puts self in client’s shoes to understand the experience from that perspective (Source: Taylor, 2008)33

34. Modes Encouraging Confident and playful Atmosphere of hope Instructing Provides structure in therapy Advices client as to the plan, the sequence Provides instructions and feedback Problem-solving Therapist as facilitator in problem-solving Strategic questioning to assist client to find solutions (Source: Taylor, 2008)34

35. Inevitable Interpersonal Events Expression of strong emotion Differs from usual by degree of intensity Emotions can be positive or negative Intimate self-disclosure Disclosure of information that is intimate, private Sensitive information about self or other (Clifford-O’Brien & Solomon, 2013, p 40) 35

36. Inevitable Interpersonal Events Power dilemmas Triggered by anything that reminds client of loss of power and control over aspects of his/her life Nonverbal cues Triggered by: Facial expressions Body language Change from informal to formal communication (Clifford-O’Brien & Solomon, 2013, p 40) 36

37. Inevitable Interpersonal Events Crisis points Unexpected events Events external to therapy Temporarily derail client from engagement in therapy Resistance and reluctance Resistance Active or passive Refusal to participate in any or all therapy There is a connection to the therapeutic relationship, or aspects of therapy (Clifford-O’Brien & Solomon, 2013, p 40) 37

38. Inevitable Interpersonal Events Reluctance The precipitating event in the lack of participation is external to the therapy Boundary testing “Pushing the limits” of the relationship Empathic breaks Therapist fails to notice or respond to client’s verbal or behavioral communication Consequently, client perceives therapist as insensitive Clifford-O’Brien & Solomon, 2013, p 40) 38

39. Inevitable Interpersonal Events Emotionally charged therapy tasks and situations Activities or tasks precipitate emotional reactions, shame, or cause client to feel humiliated Limitations of therapy Any restriction in therapy, available services, time, etc Contextual inconsistencies Can range from minimal changes in the of therapy, to inconsistencies (schedules, changes in treatment venue, etc. Clifford-O’Brien & Solomon, 2013, p 40) 39

40. Therapeutic Use Of Self and The Intentional Relationship Instructions to group: Break into work groups What was the inevitable interpersonal event? What client enduring characteristics can you identify? What situational characteristics did you observe? What modes did the nurse/therapist use? What was the outcome of this exchange? What mode might have worked better? How so? What might be the possible outcome if that/those modes were utilized? 40(Source: Taylor, 2008)

41. Communication at its best https://www.youtube.com/watch?v=3AS8lGN9-KU (Source: Taylor, 2008)41

42. Six Steps to Successful Interpersonal Reasoning Anticipate potential inevitable interpersonal events Identify them and cope with them Decide if you need to shift modes in this situation Determine what mode or sequence of modes is indicated Draw from your repertoire of interpersonal skills associated with the specific mode or mode sequence Assess effectiveness through verbal and nonverbal communication (Clifford-O’brien & Solomon, 2013) 42

43. Six Steps to Successful Interpersonal Reasoning Anticipate potential inevitable interpersonal events Observe Get information from others about their experiences interacting with the client Draw on your own previous experiences with the client Identify and cope Don’t use judgmental language, use the language from the Intentional Relationship Model to objectively manage the situation Pull yourself together Keep your “buttons” out of the reach of the client (Clifford-O’brien & Solomon, 2013) 43

44. Six Steps to Successful Interpersonal Reasoning Decide if you need to shift modes in this situation Be aware of the mode you’re currently using Determine if this current mode is producing desired effects Determine how you could best meet your client’s needs at the moment Determine what mode or sequence of modes is indicated Think of the mode or modes that tend to be more effective with your client Client responses are like a moving target; do you need to think in terms of a sequence of modes to respond to changing needs? (Clifford-O’brien & Solomon, 2013) 44

45. Six Steps to Successful Interpersonal Reasoning Draw from your repertoire of interpersonal skills associated with the specific mode or mode sequence What communication, conflict-management, or other skills can you call on? Assess through verbal and nonverbal communication how comfortable the client is after your interaction, and how effective this approach was (Clifford-O’brien & Solomon, 2013) 45

46. References American Occupational Therapy Association. (2002) Occupational Therapy Practice Framework: Domain and Process. American Journal of Occupational Therapy, 56, 609-639. American Occupational Therapy Association. (2014). Occupational Therapy Practice Framework: Domain and Process (3 rd ed.). American Journal of Occupational Therapy, 68(Supp.1), S1-S48. http://dx.doi.org/10.5014/ajot.2014.682006. http://dx.doi.org/10.5014/ajot.2014.682006 Clifford-O’Brien, J., & Solomon, J. (2013). Occupational Analysis and Group Process. MO: Elsevier Mosby. Taylor, R. (2008). The Intentional Relationship: Occupational Therapy and Use of Self. PA: F.A. Davis. 46