Intentional Relationship: Occupational Therapy and Use of

Self

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All identifying information pertaining to the client cases presented in this book has been altered to protect clients’ identity and
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Library of Congress Cataloging-in-Publication Data

Taylor, Renée R., 1970-

The intentional relationship : occupational therapy and use of self / Renée R. Taylor.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-0-8036-1365-2
ISBN-10: 0-8036-1365-2
1. Occupational therapy. 2. Allied health personnel and patient. 3. Self. I. Title.
[DNLM: 1. Occupational Therapy—methods. 2. Professional-Patient Relations. 3. Self Concept. WB 555 T245i 2008]
RM735.T326 2008
615.8′515—dc22 2007040663

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00Taylor(F)-FM 11/5/07 1:45 PM Page iii

This book is dedicated to the exceptional therapists whose work was featured in this book.
Generously, they contributed their time, personal reflections, and revealing stories of practice
to serve the interest of education and knowledge development in this under-recognized area
of occupational therapy.
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Preface
This book emerged from an ongoing curiosity and a fair amount of frustration in trying to locate a detailed,
comprehensive, and integrated textbook on therapeutic use of self specific to the field of occupational therapy.
As a professor teaching in this area, my interactions with students and practicing occupational therapists
inspired me to learn more about the interpersonal aspects of practice. As a practicing psychotherapist, I was
also interested in learning how I might blend knowledge from the field of psychology with existing occupa-
tional therapy knowledge as it pertains to the therapeutic relationship.
I began this inquiry by conducting a nationwide survey of 568 practicing occupational therapists ran-
domly selected from a membership database provided by the American Occupational Therapy Association
(Taylor, Lee, Kielhofner, & Ketkar, 2007). The objectives of this study were to determine the degree to which
occupational therapists value the client-therapist relationship, to identify variables that challenge the client-
therapist relationship, and to summarize the interpersonal strategies that are currently being used to respond to
such challenges. Results from this survey revealed that, across practice settings and client populations, prac-
ticing occupational therapists are frequently encountering clients who are demonstrating a wide range of emo-
tional, behavioral, and interpersonal difficulties. Most experienced occupational therapists place a high priority
on their interactions with clients but at the same time feel that their training in this area could have been more
sophisticated and comprehensive. The findings from this study confirmed the need for a text addressing these
issues for use by educators, students, and practitioners of occupational therapy at various levels of develop-
ment.
In preparing to write this book, I first reviewed the occupational therapy literature in order to get an idea
of the historical terrain of thinking about therapeutic use of self in the field. There is a rich history of thought
as well as changing ideals regarding what constituted effective therapeutic use of self at various times in his-
tory. As an educator and a practitioner, I am fully aware that there often exists a gap between the ideals
expressed in literature on a topic and what actually occurs in everyday therapeutic encounters. Consequently,
I sought to shape the contents of this book around practitioners’ expressions of the dilemmas and challenges
they face in therapeutic use of self as well as their descriptions of the way they attempt to manage these cir-
cumstances. Additionally, I decided to look for instances of excellence in therapeutic use of self in occupa-
tional therapy that could be shared with practicing occupational therapists, occupational therapy assistants,
educators, fieldwork supervisors, and students of occupational therapy.
This quest took me across the globe where I extensively interviewed and observed occupational therapists
who were nominated by their peers as being uniquely talented in terms of their ability to relate to a wide range
of clients. This journey taught me volumes about therapeutic use of self in occupational therapy, and my goal
is to share what I have learned with you in this book.
Renée R. Taylor

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Acknowledgments
This book would not have been possible without the ongoing support of Gary Kielhofner, who not only believed in the ideas
behind the book but also provided some of the international linkages necessary to include the work of therapists from diverse
nationalities and cultures. Also critical to the energy behind the production of this book were its acquisition editors, Christa
Fratantoro and Margaret Biblis of F.A. Davis who inspired me to think expansively about use of self. Special thanks goes
to Christa, an editor whose enduring support, creative suggestions and feedback, and ongoing belief in a novel approach
kept me going. I would also like to thank Denise LeMelledo, Deborah Thorp, Carolyn O’Brien, and Berta Steiner for their
time and care in producing this book. Finally, special thanks to the following occupational therapy students whose intelli-
gent in-class questions and critical editorial feedback helped to refine the presentation of the contents of this book. In par-
ticular, I’d like to thank Emily Ashpole, Robin Black, Joel Bové, Kim Daniello, Kelly Doderman, Barbara Flood, Mark
Kovic, Anne Plosjac, Abigail Tamm-Seitz, Rachel Trost, Jennifer Utz, Angie Vassiliou, and Debbie Victor.

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Foreword
Literally speaking, a foreword heralds in other words. Dictionary definitions describe a foreword’s aim as introductory. If
asked to choose one word to herald in this book and introduce occupational therapists to its merits, I would choose the word
well-considered. And because I have been asked to say more than one word, I’ll elaborate on my meaning.
This book is well-considered because its focus on the therapeutic use of self is timely and crucial within health care
systems struggling against pressures to compromise good intentions and relations. Taylor’s model of the intentional rela-
tionship reminds practitioners that the use of self in occupational therapy needs both theoretical and practical attention. Her
background as psychotherapist and her role as occupational therapy educator give her a unique vantage point for consider-
ing, creating, and proposing such a model.
Taylor’s work draws both power and credibility from research that explores the stories and experiences of occupational
therapists thought by their peers to possess relational artistry. From various cultures and locations, these therapists share
insights into their successful interactions. In modest ways, these master therapists offer wisdom from which practitioners of
all ages and career stages can benefit.
Itself well-considered, this book will foster consideration among its readers. Taylor’s reflective exercises invite the
development of values essential to the therapeutic use of self. We know that interpersonal skills learned in the absence of
values that nurture them fall short of being therapeutic. Use of self that is conscious requires reflection sufficient to develop
an awareness of personal traits, intentions, and actions. Use of self that is therapeutic presses past such awareness, asking
that practitioners enact the respect and empathy that honor human dignity. Because it invites individuals to consider their
interactions within the moral context of professional lives, the book is a call to mindfulness.
Although an enormous step in itself, understanding of the human need for respect and empathy is not enough. Such
understanding must be paired with solid learning of effective approaches to meeting that need. This book fosters such learn-
ing through open discussions of behaviors that cause empathic breaks and through practical guidelines for meeting personal
challenges found in daily practice. Because students hunger for such knowledge, this book will have educative power.
I have spent much time in thought, writing, and teaching about the therapeutic use of self. I value work on the topic
that is well-considered. This book is such a work. Taylor and I share the belief that the therapeutic use of self is the
essential stuff of occupational therapy rather than its “fluff.” Promise and power lie within this book, and I am pleased to
herald it in.
Suzanne M. Peloquin, PhD, OTR, FAOTA

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Contributors
Kristin Alfredsson Ågren, MScOT, RegOT Stephanie McCammon, MS, OTR/L
Dagcenter Valla University of Illinois Medical Center
Linköping, Sweden Chicago, Illinois

Belinda Anderson, MEd, MS, OTR/L Roland Meisel, MS, OTR/L

Select Medical A-Rehab, Inc.
Skokie, Illinois Stockholm, Sweden
Chicago Lighthouse for the Blind and Visually Impaired
Chicago Board of Education Jane Melton, MSc (Advanced OT), DipCOT (UK)
Chicago, Illinois Gloucestershire Partnership
National Health Service Trust
René Bélanger, OTR, MBA Gloucestershire, United Kingdom
Hôtel-Dieu de Lévis Hospital
Laval University Anne Reuter, State-Approved Occupational Therapist
Quebec City, Quebec, Canada In Motio Outpatient Rehabilitation Center
Plauen, Germany
Carmen-Gloria de Las Heras, MS, OTR/L
Reencuentros Michele Shapiro, OTR, Doctoral Student
Santiago, Chile Beit Issie Shapiro Community Organization
Raanana, Israel
Kim Eberhardt, MS, OTR/L
Rehabilitation Institute of Chicago
University of Illinois at Chicago
Chicago, Illinois

Vardit Kindler, OTR/L, MEd

Dvora Agmon Preschool, Israel Elwyn
Mish’aul – The Israeli Center for Augmentative
Communication and Assistive Devices
Jerusalem, Israel

Kathryn M. Loukas, MS, OTR/L, FAOTA

Raymond School District
Raymond, Maine
University of New England
Bitteford, Maine

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Reviewers
Bette R. Bonder, PhD, OTR/L, FAOTA Terry L. Jackson, MS, OTR, LCDC
Associate Dean Coordinator of Education
Occupational Therapy Rehabilitation Sciences
Cleveland State University University of Texas Medical Branch
Cleveland, Ohio Galveston, Texas

Elizabeth Cara, PhD, OTR/L, MFT Barbara Kresge, MS, OTR

Associate Professor Lecturer and Admissions Chair
Occupational Therapy Occupational Therapy
San Jose State University Tufts University
San Jose, California Boston, Massachusetts

Mariana D’Amico, EdD, OTR/L, BCP Jaime Munoz, PhD

Assistant Professor Assistant Professor
Occupational Therapy Occupational Therapy
Medical College of Georgia Duquesne University
Augusta, Georgia Pittsburgh, Pennsylvania

Janis Davis, PhD, OTR Jane Clifford O’Brien, PhD

Assistant Professor Assistant Professor
Occupational Therapy Occupational Therapy
Rockhurst University University of New England
Kansas City, Missouri Biddeford, Maine

Christine deRenne-Stephan, MA, OTR/L Marjorie E. Scaffa, PhD, OTR, FAOTA

Visiting Clinical Professor Program Director
Occupational Therapy Occupational Therapy
University of Puget Sound University of South Alabama
Tacoma, Washington Mobile, Alabama

Linda S. Fazio, PhD, OTR/L, FAOTA, LPC Victoria P. Schindler, PhD, OTR, FAOTA
Associate Professor Associate Professor
Occupational Therapy Occupational Therapy
University of Southern California Richard Stockton College
Los Angeles, California Pomona, New Jersey

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xii Reviewers

Sharan L. Schwartzberg, EdD, OTR, FAOTA Janet H. Watts, PhD, OTR

Professor and Chair Emeritus Associate Professor
Occupational Therapy Occupational Therapy
Tufts University Virginia Commonwealth University
Boston, Massachusetts Richmond, Virginia
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Contents
PART I Theoretical Foundations and
Guidelines for Practice
1 The Changing Landscape of Therapeutic Use of Self
in Occupational Therapy: Historical Overview . . . . . . . . . . . . 3
2 What Defines a Good Therapist? . . . . . . . . . . . . . . . . . . . . . 19
3 A Model of the Intentional Relationship . . . . . . . . . . . . . . . . 45
4 Knowing Ourselves as Therapists: Introducing the
Therapeutic Modes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
5 Knowing Our Clients: Understanding Interpersonal
Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
6 Challenges to Client–Therapist Relationships: Inevitable
Interpersonal Events of Therapy . . . . . . . . . . . . . . . . . . . . . 117
7 Navigating the Challenges: Therapeutic Responding
and Interpersonal Reasoning . . . . . . . . . . . . . . . . . . . . . . . . 135

PART II Building an Interpersonal Skill Base

8 Therapeutic Communication . . . . . . . . . . . . . . . . . . . . . . . . 157
9 Establishing Relationships . . . . . . . . . . . . . . . . . . . . . . . . . 177
10 Interviewing Skills and Strategic Questioning . . . . . . . . . . . 195
11 Understanding Families, Social Systems, and
Group Dynamics in Occupational Therapy . . . . . . . . . . . . . 209

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xiv Contents

12 Understanding and Managing Difficult Behavior . . . . . . . . 231

13 Resolving Empathic Breaks and Conflicts. . . . . . . . . . . . . . 253
14 Professional Behavior, Values, and Ethics . . . . . . . . . . . . . . 261
15 Working Effectively with Supervisors, Employers,
and Other Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
16 On Becoming a Better Therapist: Self-Care
and Developing Your Therapeutic Use of Self . . . . . . . . . . . 297

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
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PA RT I

Theoretical Foundations
and Guidelines for Practice
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CHAPTER 1

THE CHANGING LANDSCAPE

OF THERAPEUTIC USE OF SELF
IN OCCUPATIONAL THERAPY:
An Historical Overview
I n a recent national study of 568 practicing occupational
therapists in the United States, more than 80% of
respondents rated therapeutic use of self as the most
Occupational Therapy Association, 2002). Many educa-
tional programs have only just begun to consider develop-
ing required courses that focus solely on this topic, such as
important determinant of the outcome of therapy (Taylor, the one developed by Peloquin and Davidson (1993). Only
Lee, Kielhofner, & Ketkar, 2007). However, less than half 4% of the therapists who responded to the national study
of these therapists thought they were adequately trained in reported that they took a course focused only and specifi-
use of self upon graduation. Moreover, less than one-third cally on the therapeutic use of self (Taylor et al., 2007).
thought there was sufficient knowledge about use of self in Finally, the gap identified by therapists between the
occupational therapy (Taylor et al., 2007). importance of therapeutic use of self and their field’s inad-
These therapists’ perceptions of the importance of equate knowledge about this area is reflected in the current
therapeutic use of self are supported by other research literature of the profession. On one hand, the field has
studies. A growing number of studies indicate that the adopted strong values related to the importance of the use
client–therapist relationship is a key determinant of of self in practice. On the other hand, few detailed and
whether occupational therapy has been successful (Ayres- extensive descriptions of therapeutic use of self skills for
Rosa & Hasselkus, 1996; Cole & McLean, 2003). These practice actually exist. Thus, the literature of the field leads
findings are paralleled by extensive evidence in the field of one to conclude that, although therapeutic use of self is
psychology that a positive therapeutic relationship is the critically important, how to do it is somewhat abstract. The
only variable consistently associated with successful psy- aim of this book is to offer a specific conceptualization of
chotherapy outcomes (Bergin & Garfield, 1994; Orlinsky, therapeutic use of self and make concrete the skills
1994). Moreover, the demonstrated relation between a pos- involved (Box 1.1).
itive therapeutic relationship and good therapy outcomes is
strong and consistent across highly distinct and often the-
oretically opposing orientations to practice (Fig. 1.1). History of Therapeutic Use
Additionally, the occupational therapists’ opinions
that their education did not adequately prepare them to
of Self in Occupational
manage challenging interpersonal situations in practice Therapy
are also understandable. Only recently was the use of self
included as one of the major categories of intervention in Although occupational therapy does not have a consistent
the occupational therapy practice framework (American conceptualization of therapeutic use of self, the topic has

3
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4 Part I Theoretical Foundations and Guidelines for Practice

FIGURE 1.1 Jane Melton considers use

of self as highly relevant to her practice

been addressed throughout the field’s history. Ideas about ment era (Bing, 1981; Bockoven, 1971). Moral treatment
how therapists should interact with clients have changed as was a humanitarian approach that emphasized the facilita-
the field’s conceptualization of its practice has been trans- tion of self-determination through engagement in everyday
formed. Examining these different perspectives on thera- tasks and activities. Consideration and kindness were put
peutic use of self provides an important backdrop for forward as essential interpersonal values. Supporters of
understanding where to begin when conceptualizing the moral treatment also argued that all activity prescriptions
use of self in contemporary occupational therapy. should be based on in-depth understanding of the client’s
Historical analysis has identified three distinct eras preferences and interests (Bing, 1981).
in occupational therapy, characterized as paradigms
(Kielhofner, 2004). The earliest occupational paradigm Early Occupational Era
reflected the humanistic ideas and practices of the field’s When occupational therapy emerged during the 20th cen-
founders. This paradigm built on the ideas of earlier Euro- tury, its leaders emphasized the humanistic approaches of
pean moral treatment. It focused on the individual’s expe- moral treatment (Kielhofner, 2004; Schwartz, 2003). Cen-
rience of doing and on his or her capacity and motivation tral to the thinking during this era was that the therapeutic
to function during interaction with physical and social relationship served as a means by which to encourage
environments. This first paradigm was replaced during the engagement in occupation. The field’s early leaders recog-
mid-20th century by a paradigm of inner mechanisms that nized that the success of therapy depended on the ability of
ushered in concern for addressing clients’ underlying the therapists to persuade or motivate clients (who often
impairments. Rooted in the medical establishment, this were in negative frames of mind) to undertake the occupa-
paradigm sought to correct internal failures of body and tions they were being offered as therapy.
mind. During the latter part of the 20th century a new, con- One early leader, Susan Tracy, argued that the thera-
temporary paradigm returned the field to its initial focus pists should appeal to the intrinsically attractive and satis-
on occupation. As we will see, each of these eras had its fying nature of activities. She saw the therapeutic role as
own particular approach to the therapeutic use of self. one of suggesting possibilities and finding inviting ways to
present opportunities for action. Tracy, along with another
Moral Treatment early founder of occupational therapy, Dunton, empha-
Nascent descriptions of therapeutic use of self were intro- sized the importance of occupational therapists being
duced in Europe in the late 1700s during the moral treat- skilled craftspeople who could serve as positive role mod-
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Chapter 1 Changing Landscape of Therapeutic Use of Self 5

Box 1.1 Definitions of the Therapeutic Use of Self

M osey (1981, 1986) described the conscious use of self as deceitful ways toward clients. Instead, artfulness referred to
the ability to deliberately use one’s own responses to clients as selecting aspects of one’s own personality, attitudes, values,
part of the therapy. She characterized use of self as a “legiti- or responses that were predicted to be relevant or helpful in a
mate” skill across all frames of reference. To select appropriate given situation. In turn, therapists were expected to control or
ways to respond to a client, the therapist had to possess self- suppress those aspects of self that were not appropriate for the
awareness, empathy, flexibility, humor, honesty, compassion, situation. According to Hagedorn, therapists were not expected
and humility. to be perfect; instead, they were expected to be aware of their
Denton (1987) similarly described use of self as conveying strengths and limitations, sensitive, honest, and genuine with
an attitude of respect and acceptance to clients so self-esteem clients. Therapists were also expected to manage stress effec-
could be restored. Self-esteem could also be enhanced by the tively and to have personal integrity.
way in which a task or activity was presented to the patient. Cara and MacRae (1998) defined therapeutic use of self
In addition, a therapist was considered effective in his or as developing an individual style that promotes change and
her use of self if he or she succeeded in modeling charac- growth in clients and helps furnish them with a corrective
teristics of a mature, competent, and admirable person for emotional experience. A corrective emotional experience is
the client. one in which a therapist’s behavior toward a client during ther-
Schwartzberg (1993) defined therapeutic use of self as apy contradicts the way others have behaved toward the client
comprising understanding, empathy, and caring. Effective use in the past and demonstrates to the client that he or she is wor-
of self was defined as remaining neutral but engaged, accept- thy of caring and empathy.
ing the client as he or she is, being tolerant and interested in Punwar and Peloquin (2000) defined the therapeutic use of
the client’s painful emotions, and being able to interpret the self as a “practitioner’s planned use of his or her personality,
client’s expectations of therapy accurately. insights, perceptions and judgments as part of the therapeutic
Hagedorn (1995) defined therapeutic use of self as the art- process” (p. 285). This definition was also used in the Ameri-
ful, selective, or intuitive use of personal attributes to enhance can Occupational Therapy Association’s Occupational Therapy
therapy. Hagedorn clarified that the notion of an artful use of Practice Framework (American Occupation Therapy Associa-
self should not be misconstrued as behaving in artificial or tion, 2002).

els for standards of performance and appreciation for pate in occupations, demonstrate standards of performance
crafts (Dunton, 1915, 1919; Tracy, 1912). Dunton (1915, in sportsmanship and craftsmanship, and emulate the
1919) and two other founders, Meyer (1922) and Slagle enjoyment and satisfaction that came from doing things.
(1922), underscored the importance of understanding the Thus, during the early occupational era, the therapeu-
personalities of clients so therapists would know what tic relationship was one in which the therapist served as:
activities were likely to appeal to those clients.
• Expert, or guide, in the performance of therapeutic
In addition to appealing to clients’ innate dispositions
activities, such as arts, crafts, and sports
and using the intrinsic attraction to occupations, another
• Role model for occupational engagement
approach was to appeal to the client’s sense of the impor-
• Emulator of the joy of occupation
tance of participating in therapy. For example, Haas
• Instiller of confidence
(1944) thought it important to instill faith in the client con-
• Creator of a positive physical and social milieu
cerning the therapeutic process. He recommended that the
physician introduce each client to the occupational therapy To a large extent, the therapist’s use of self was to
director to underscore the value of occupational therapy and set the stage for a client to wish to engage in therapeutic
to build the patient’s confidence in the treating therapist. occupations and to have a positive experience when doing
At this time, the physical and social environments so. The therapeutic relationship required the therapist
were also emphasized as client motivators (Bing, 1981; to serve as a kind of master of ceremonies who orches-
Kielhofner, 2004). Thus, the therapist functioned to ensure trated the environment and the unfolding process of occu-
that the physical context and social milieu was attractive pational engagement. The therapist also needed to get
and inviting and that it embodied a positive esprit de corps, to know the client through interactions and interviews,
order, and utility. Interpersonally, the occupational thera- thereby learning how to appeal to the person’s innate inter-
pist behaved in ways that would invite the client to partici- ests and personality.
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6 Part I Theoretical Foundations and Guidelines for Practice

Era of Inner Mechanisms 1959; Fidler & Fidler, 1954, 1963). The second perspec-
Beginning during the 1940s, the second, mechanistic par- tive, heavily influenced by the work of Frank (Box 1.2)
adigm replaced the earlier humanistic one. This new per- used activities to establish a therapeutic relationship that
spective focused occupational therapists on remediating would permit the person to develop healthy means of
the internal biomechanical, neuromuscular, and intrapsy- resolving intrapsychic conflict and fulfilling needs. The
chic mechanisms of the body and mind that influenced following quote illustrates this approach.
function (Kielhofner, 2004). During this time, there was an
The effective therapeutic approach in occupational therapy
important change in emphasis on the role of the therapeu-
today and in the future is one in which the therapist
tic relationship (Peloquin, 1989a). utilized the tools of his trade as an avenue of introduc-
First, this paradigm included the emphasis on elimi- tion. From then on his personality takes over. (Conte,
nating pathology, borrowed from the medical model. 1960, p. 3)
It also included medicine’s ideas about expertise and
authority; these had a strong influence on occupational Given this new emphasis, the occupation or activity
therapy’s view of the use of self. In this framework, thera- lost its unitary importance (Kielhofner, 2004). Instead, the
pists were expected to assume an impersonal and profes- central focus was on the cathartic and corrective relation-
sional attitude toward clients while at the same time ship between therapist and client.
commanding respect, demonstrating exceptional compe-
tence, and conveying a hope for cure (Wade, 1947). Tact,
self-control, listening skills, impersonal objectivity, good
judgment, and the ability to identify with a patient were Box 1.2 Jerome Frank
emphasized as “personality qualifications” of a good I n 1958 during the mechanistic era, Jerome D. Frank,
therapist (Wade, 1947). a psychiatrist, introduced the term “therapeutic use of
During this era, occupational therapy was also self” to the field of occupational therapy. Frank (1958)
heavily influenced by psychoanalytic (i.e., Freudian and introduced psychiatry’s definition of self as a term that
Neo-Freudian) concepts. Emotional, psychiatric, and inter- encompasses every aspect of personality development
personal difficulties were considered aspects of internal and interpersonal behavior. Frank held that the develop-
pathology that needed to be treated using approaches that ment of a client’s healthy self can be derailed by incon-
focused heavily on the relationship that existed between sistent or derogatory parental attitudes, constitutional
the therapist and the client. It was at this time that the term variables (innate temperament), and physical impair-
ments. He further argued that these interruptions in nor-
“therapeutic relationship” first emerged.
mal development of self resulted in what was referred to
According to this new view, it was important for the as a “pathological self-structure.” In relationships, a
occupational therapist to attend to how a client behaved pathological self-structure can manifest in one of two
toward activities within the therapeutic relationship in ways: It can result in a restricted or overly rigid use of a
order to understand the client’s inner motives, interper- small set of interpersonal strategies, or it can result in a
sonal feelings, and relationships with others. For example, diffuse self that has not built adequate self–other bound-
the type of product a client chose to make in therapy and aries and responds to the demands of all others and all
the way the client went about the activity were viewed as situations without discrimination. In either case, Frank
shedding light into the client’s inner motives and feelings argued that the mechanism of repairing a client’s frag-
toward the therapist or others. Such factors as the client’s mented self structure involved the self of the therapist.
That is, the therapist must use his or her self as a mecha-
choice of color, degree of dependence on the therapist, and
nism for repairing a client’s damaged self. Thus, a thera-
preference for different procedures or tasks were all win- pist’s self structure needed to be strong enough to endure
dows into the client’s psyche. threats wrought by the demands and projections of a
A range of ideas was put forward about the nature of client’s pathological self. In addition, Frank held that it
the therapy during this period, but there were two domi- was important for the occupational therapist to show
nant themes. The first argued that the client would achieve competence; resist the need to reassure; act clearly, con-
catharsis through acting out unconscious desires and sistently, predictably, spontaneously, and flexibly; and
motives while performing activities and simultaneously remain ambiguous at times to force the client to cope
gaining insight into these underlying issues through dis- with stress and manage problems independently.
cussion and relating with the therapist (Azima & Azima,
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Chapter 1 Changing Landscape of Therapeutic Use of Self 7

Both approaches saw activity as augmenting the talk It was acknowledged that this balance varied from patient
that took place in psychotherapy. Importantly, they carried to patient.
a very different connotation As evident in the ideas
about the interpersonal role of these and other seminal
of the therapist from the pre- Whereas the therapist’s contributors of the time, the
vious era. Whereas the thera- closer relationship with med-
pist’s role was previously to role previously was to icine and support for the
appropriately orient the
client to occupations that
appropriately orient the medical model was reflected
in all aspects of occupational
were used as therapy, this
new framework argued that
client to occupations that therapy practice. In the spe-
cialty area of psychosocial
the relationship between the were used as therapy, this occupational therapy, the
therapist and the client was practice of occupational ther-
the key dynamic of therapy. new framework argued that apy was becoming strikingly
These ideas, which were
first developed in psychiatric
the relationship between similar to the practice of psy-
chotherapy. This, in conjunc-
settings, became the domi-
nant way of thinking about
the therapist and the client tion with the recognition
that occupation had lost its
the therapeutic relationship was the key dynamic place as the key dynamic
throughout the entire field. of therapy, led some of the
Thus, during the inner of therapy. key contemporary leaders
mechanisms era, the thera- to reevaluate the field’s iden-
peutic relationship was viewed as: tity and direction (Kielhofner, 2004; Schwartz, 2003;
Shannon, 1977; Yerxa, 1967).
• A central mechanism for change
• A means by which to understand a client’s unconscious
motives, desires, and behavior toward others Return to Occupation
• An avenue through which an individual could achieve Beginning during the 1960s, Reilly (1962) was the first to
catharsis through acting out unconscious desires and notice that the field of occupational therapy was drifting
motives and gain insight into issues that were at the away from a focus on occupation and away from its origi-
core of pathological feelings and behaviors nal values, which were based on concepts of moral treat-
ment. Moreover, the psychoanalytical/neo-Freudian focus
When relating to clients, the therapist was expected to on the therapeutic relationship was seen as having “side-
demonstrate: lined” the central role of occupation (Kielhofner and
• Competence Burke, 1977). The view that the therapeutic relationship
• Professionalism was the key dynamic of therapy was rejected in favor of
• Impersonal objectivity occupational engagement as the true dynamic. Once again,
• Hope the therapist was viewed as a proponent of occupational
• Tact engagement who must use a variety of strategies to make
• Self-control occupations appealing and to support the therapy process.
• Good judgment
• Identification with the patient
Although some of these interpersonal behaviors may Contemporary Discussions
appear contradictory (e.g., identification with the patient
versus maintaining interpersonal objectivity), they were
of the Client–Therapist
not viewed as such at the time. According to the views of Relationship
this era, the ideal therapeutic relationship involved striking
an appropriate balance between having compassion for Alongside this contemporary emphasis on occupation,
a patient and acting in an optimally therapeutic manner. new discussions concerning the client–therapist relation-
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8 Part I Theoretical Foundations and Guidelines for Practice

ship have emerged (Cara & MacRae, 2005; Cunning- In addition to care and planning in relationships,
ham-Piergrossi & Gibertoni, 1995). For example, the respect for diversity and cultural sensitivity in practice
occupational therapy literature has argued that a collabora- were also introduced during the contemporary era.
tive relationship that is egalitarian and empowering of Although this area is in need of continued development,
clients leads to improved treatment outcomes (Anderson & cultural competence and awareness of the potential for
Hinojosa, 1984; Ayres-Rosa & Hasselkus, 1996; Clark, personal biases are considered fundamental to building
Corcoran, & Gitlin, 1995; Hinojosa, Anderson, & Strauch, effective relationships (Bonder, Martin, & Miracle, 2001;
1988; Hinojosa, Sproat, Mankhetwit, & Anderson, 2002; Lloyd & Maas, 1991, 1992; Wells & Black, 2000).
Townsend, 2003). As can be readily seen, a variety of contemporary
In addition, caring, empathy, connection, personal descriptions of the conditions necessary for an effec-
growth, and effective verbal and nonverbal communica- tive therapeutic relationship have been put forward. From
tion skills have been characterized as important qualities these numerous ideas, three major themes can be gleaned
for successful occupational therapy practice (Cole & in contemporary discussions of the client–therapist rela-
McLean, 2003; Devereaux, 1984; Eklund & Hallberg, tionship.
2001; King, 1980, 1994; Lloyd & Maas, 1991, 1992;
Peloquin, 2005). There has been a particularly strong • Collaborative and client-centered approaches
emphasis on the appreciative and empathic process by • Emphasis on caring and empathy
which the therapists come to truly understand clients’ life • Use of narrative and clinical reasoning
stories and to feel deep respect for and trust in the clients’
The remainder of this section summarizes the key
perspectives on their experiences (Hagedorn, 1995;
concepts in each of these thematic areas.
Mosey, 1970; Peloquin, 1995, 2005; Punwar & Peloquin,
2000). Some have argued that therapist self-knowledge,
self-awareness of behavior, and the ability to self-evaluate Collaborative and Client-
or reflect on one’s practice are prerequisites for inter- Centered Approaches
personal sensitivity and the capacity for greater under- In contrast to the mechanistic era when the field empha-
standing of a client’s narrative (Hagedorn, 1995; Mattingly sized professionalism, objectivity, and a more analytical
& Fleming, 1994; Schell, Crepeau, & Cohn, 2003; Schon, approach to the relationship, a strong value of the contem-
1983) (Box 1.3). porary era has been that of collaboration, mutuality, and
client-centered practice.

Box 1.3 Ann Mosey Collaborative Approaches

In 1981, Mosey coined the term “conscious use of self.” Mosey (1970) was one of the first to write about the value
According to Mosey (1981), therapists should respond to of collaboration when planning treatment goals and evaluat-
clients in a thoughtful and planned way rather than in a ing therapy outcomes. Mosey (1986) emphasized a number
spontaneous or impulsive way. Mosey (1986) explained of qualities necessary for the formation of collaborative
that therapists should “manipulate” their responses to relationships, including flexibility, humility, self-awareness,
clients to accommodate the interpersonal demands of empathy, humor, honesty, and compassion. One of the cen-
therapy. The rationale behind this approach is that each tral therapeutic strategies of early descriptions of collabora-
client has different interpersonal needs, and clinical situa-
tion involved educating clients about all aspects of the
tions and context may vary widely from client to client.
Because of this variability, a therapist cannot respond in
treatment process and providing them with information
the same way to each client. According to Mosey, planned about the purpose and relevance of any procedure or treat-
responses to clients can serve to reduce a client’s anxiety, ment approach (Peloquin, 1988). According to this perspec-
provide support, or obtain or share needed information. tive, providing these rationale statements at each session
Depending on the needs of the client, the conscious use was thought to facilitate increased client involvement in
of self may include dialogue, gestures, facial expressions, therapy (Peloquin, 1988).
touch, or the use of special talents (Mosey, 1981). Collaborative perspectives assume that power imbal-
ances are inherent in all client–therapist relationships, and
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Chapter 1 Changing Landscape of Therapeutic Use of Self 9

that therapists can seek to readjust these imbalances by knowledge about how best to approach the child’s disabil-
facilitating client control over decision-making and by ity, and fewer opportunities to receive positive
encouraging the client to become actively involved in reinforcement for good parenting skills. Because of this
problem-solving about his or her own situation (Hagedorn, potential for rifts and power differentials in the therapeutic
1995; Townsend, 2003). In support of this approach, a relationship, a number of researchers recommend that
number of occupational therapy writers have incorporated therapists employ collaborative strategies to enable service
the ideas of Schon (1983), who contrasted two types of recipients to build a sense of their own self-efficacy as
contracts that characterized the therapeutic relationship: parents or caregivers (Anderson & Hinojosa, 1984; Clark
the hierarchical professionalism typical of the inner mech- et al., 1995; Hanna & Rodger, 2002; Hinojosa et al., 2002;
anisms era and what he labeled a “reflective contract” in Rosenbaum, King, Law, King, & Evans, 1998). This spirit
which the client assumes control, becomes more educated, has been reflected in the literature on family-centered
and joins with the professional in solving problems related care (Hanna & Rodger, 2002; Rosenbaum et al., 1998).
to his or her situation. Rather than presuming total and These strategies (Anderson & Hinojosa, 1984; Hanna &
complete expertise, Schon (1983) encouraged therapists to Rodger, 2002; Rosenbaum et al., 1998) emphasize self-
think critically about their experiences and behaviors both efficacy as one of the most valued anticipated outcomes
in the midst of performing therapy and once the practice (Baum, 1998).
session ended. Similar collaborative approaches have been applied
The collaborative approach has also been discussed to a wide range of occupational therapy clients of all ages.
with regard to relationships with parents of pediatric For example, Clark et al., (1995) researched the interper-
clients in occupational therapy (Anderson and Hinojosa, sonal behaviors of two occupational therapists interacting
1984; Hanna & Rodger, 2002). The rationale behind with caregiver-clients. Therapist behaviors were summa-
this approach is that some parents of children with disabil- rized in terms of four categories: caring (being supportive,
ities may feel undermined or undervalued by therapists friendly, and building rapport); partnering (gathering
who focus too much on direct therapy with the child reflective feedback and seeking and acknowledging input
and assume an expert stance in the therapeutic relation- from clients); informing (gathering, explaining, and clari-
ship. Parental feelings of vulnerability may stem from fying information); and directing (providing advice and
difficulties accepting the fact a child is disabled, lack of instruction) (Fig. 1.2).

FIGURE 1.2 Roland Meisel values collab-

oration as an important aspect of work
rehabilitation