The interaction between an occupational therapy (OT) practitioner and a client is termed the therapeutic relationship. Therapeutic relationships differ from everyday relationships, in that therapeutic relationships are key for facilitating the healing and rehabilitation process. Therefore, OT practi-tioners create therapeutic relationships to help clients achieve their desired goals. This chapter examines the uniqueness of the therapeutic relationship by describing this relationship in terms of therapeutic use of self, self-awareness, and trust. Skills practitioners use in developing the relationship are presented including trust, empathy, nonverbal and verbal communication, active listening, and group leadership skills. Sample cases throughout the chapter provide readers with descriptions of how therapeutic relationships are used in practice.

Psychology of Rehabilitation

People who experience catastrophic trauma or illness, disease, or developmental disorders have emotional and physical needs. Occupational therapy practitioners address both the physical and emotional needs of clients. The profession views clients holistically, meaning that practitioners treat the whole person in an individualized way. This involves understanding the client and his or her motivations, desires, and needs. To understand a client in this way, practitioners create a therapeutic relationship with each client. Through this unique relationship, the practitioner learns how to design activities which are internally motivating and meaningful to a client and best meet the client’s goals.³

Oftentimes it is the practitioner’s ability to develop the therapeutic relationship that contributes to the success of the intervention.^3,⁷

75-year-old Gordon received OT intervention after a stroke. The practitioner set up a simple task of grasping clothespins to address his poor hand skills. However, as he worked to grasp the clothespins, the practitioner sat and talked to him. Gordon valued this relationship and looked forward to attending his sessions. He felt that his time in OT was well spent and that he was improving.

In retrospect, the value of this session was not so much in the fine motor task the practitioner provided, but rather due to the fact that she sat there and talked with him. In earlier years, Gordon’s three daughters (who now all lived far away) frequently sat and talked to him in the same way as the practitioner did. He enjoyed this familiar occupation and this motivated him to continue in his therapy. His wife felt assured that he was engaged in therapy when she was not there, which relieved her. This example shows the power of the therapeutic relationship.

Many clients receiving occupational therapy experience a sense of loss. They may lose function, health, occupations, or time. They may realize that they have a chronic illness that will require their attention. Elisabeth Kübler-Ross defined the universal stages of loss as denial, anger, bargaining, depression, and acceptance.⁴ Clients may go through some or all of these stages during the intervention process. The process is dynamic and clients may revisit earlier stages. The OT practitioner recognizes these stages and provides support and opportunities to help clients work through the stages.

It is essential that the practitioner not judge the client’s progression through the stages since each person and family deals with experiences differently. For example, it is not helpful for the practitioner to judge how long a mother is allowed to grieve for her child’s lack of development. Parents may continually grieve normal milestones and need the practitioner’s support. OT practitioners who are sensitive to the emotional impact of loss are more effective in developing therapeutic relationships and helping clients progress.

Therapeutic Relationship

Therapeutic relationships differ from friendships. In friendships, each person contributes to and receives from the relationship, whereas the goal of the therapeutic relationship is for one person (the client) to benefit. While the practitioner often receives a “reward,” in helping another person, it is not the intention or design of the interaction.

In every therapy session, the OT practitioner is aware of the client’s needs and uses technical and interaction skills to select responses or courses of action that benefit the client. The therapeutic relationship often makes the difference between a successful and an unsuccessful therapy experience. The practitioner continually assesses his or her interaction skills and makes judgments about how to use the skills to help the client. This process of using one’s interactions for the benefit of another is referred to as “the art of relating” and termed the therapeutic use of self. Therapeutic use of self involves awareness of oneself, including such things as how one communicates, presents, and relates with others.¹

Intentional Relationship Model

Taylor developed the Intentional Relationship Model, which systematically describes therapeutic use of self and the development of modes of interacting with clients for their benefit.⁷ The Intentional Relationship Model defines six primary interpersonal modes (or styles) used in therapeutic relationships: advocating, collaborating, empathizing, encouraging, instructing, and problem-solving.⁷

Taylor postulates that the intentional relationship works best when therapists are aware of their modes of interacting and are able to shift modes as needed.⁷ Taylor provides techniques and exercises to develop skill and awareness in therapeutic use of self. See Box 16-1 for examples of modes.

Box 16-1 Therapeutic Modes and Examples

Mode	Practice Example
Advocating	• Justifies the need for OT services in the school system to help the child complete schoolwork • Consults with employer on workplace accommodations that would allow client to return to work
Collaborating	• Develops goals and strategies with client • Modifies intervention plan based upon client’s input
Empathizing	• Actively listens to client’s story • Adjusts intervention session to meet client’s needs
Encouraging	• Suggests that the client “do one more repetition” • Provides positive reinforcement
Instructing	• Teaches the client to dress using one hand • Reviews precautions for the condition • Demonstrates use of adaptive equipment or technology
Problem- solving	• Figures out with client how to perform daily living skills • Examines with client how to access resources • Modifies equipment to meet the client’s needs

Modes from Taylor RR: The Intentional Relationship: Use of Self and Occupational Therapy, Philadelphia, 2008, FA Davis.

Basic Therapeutic Use of Self Principles

Several principles are basic to therapeutic use of self. First, practitioners must possess a level of self-awareness so that they can mindfully examine their role in the intervention process. Secondly, practitioners learn to develop trust, provide support, actively listen, and empathize. They use genuineness, respect, self-disclosure, trust, and warmth when interacting with clients.² These qualities are useful in establishing and sustaining therapeutic relationships.

Self-Awareness

Self-awareness refers to knowing one’s own true nature; it is the ability to recognize one’s own behavior, emotional responses, and effect on others. Occupational therapy practitioners learn to be aware of their own strengths and weaknesses in order to better serve clients. Understanding one’s own strengths and limitations allows the practitioner to focus on the other person and adapt one’s behavior and interactions with others.

Becoming aware of one’s self requires introspection in terms of the ideal self, the perceived self, and the real self. The ideal self is what an individual would like to be if free of the demands of mundane reality. This aspect is the “perfect self,” with only desirable qualities and with all wants and wishes fulfilled. The ideal self is unrealistic and includes all intention, feeling, and desires. It is not well known to others, although people frequently feel the need to defend the ideal self (though perhaps subconsciously) when others do not acknowledge it.

The perceived self is the aspect of self that others see without the benefit of knowing a person’s intentions, motivations, and limitations (i.e., as defined only by outward behavior). Therefore, the perceived self is not the true self. Many times the perceived self is different from the ideal self’s perceptions.

The real self is a blending of the internal and external worlds involving intention and action plus environmental awareness. The real self includes the feelings, strengths, and limitations of the person, as well as the reality in which the person exists (his or her environment).

A lack of self-awareness may result in distorted self-perceptions that are destructive to “real” relationships. People who are busy defending the ideal self and denying the perceived self do not allow the real self to emerge and consequently have superficial or misunderstood relationships, whereas a self-aware person is able to realistically acknowledge his or her own strengths and limitations and adapt and modify behaviors to help others or engage in healthy relationships. Practitioners with self-awareness are able to help clients who are struggling with new identities and crises.

Self-Awareness Exercises