Therapeutic Use of Self - Florida Occupational Therapy Association

Report
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
Course Objectives:
At the completion of this course, participants will be able to:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Discuss the Occupational Therapy Practice Framework as a guiding
document of practice, and it’s relationship to the therapeutic use of
self.
Define therapeutic use of self and the intentional relationship and
their application in the therapeutic relationship
Understand the emergence, decline, and re-emergence of therapeutic
use of self in occupational therapy practice
Demonstrate an understanding of therapists’ interpersonal
characteristics, and identify their own.
Demonstrate an understanding of clients’ characteristics
Discuss the difference between clients’ enduring, and situational
characteristics that can affect the therapeutic relationship
Demonstrate an understanding of therapeutic modes
Describe and compare therapeutic modes and their application in
practice
Apply the use of therapeutic use of self, to manage inevitable events of
therapy
Articulate the benefits of incorporating therapeutic use of self to
support the therapeutic relationship and improve outcomes of
therapy
2
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
(Source: Taylor, 2008)
3
 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
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 clientcentered and focused on engagement in occupation (AOTA, 2014)
AOTA, 2014
5
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
(Source: Taylor, 2008)
6
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
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
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
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
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
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
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
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
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
Therapeutic Use Of Self
and The Intentional Relationship
 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)
16
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
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
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
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
(Source: Taylor, 2008)
20
Therapeutic Use Of Self in Psychotherapy
The
Client
Interpersonal
Relating
The
Therapist
(Taylor, 2008, p 46)
21
The Relationship In OT
(Taylor, 2008, p 46)
The Client
Occupational Engagement
(focus of occupational
therapy interventions)
The
Occupation
Interpersonal Relating
(reciprocal, between therapist
and client)
Treatment approaches,
activities, and strategies
selected to improve
performance
The
Occupational
Therapy
Practitioner
22
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
This Intentional Relationship Model inhabits the space where the therapist
engages in Interpersonal Relating with the client
The client will have his or her own
interpretation of and reaction to the
event
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
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
It is the therapist’s
responsibility to utilize
therapeutic responding
rather than reacting, to
address the inevitable
interpersonal event
with the client.
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
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)
(Source: Taylor, 2008)
25
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
(Source: Taylor, 2008)
26
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
(Source: Taylor, 2008)
27
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
(Source: Taylor, 2008)
28
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
(Source: Taylor, 2008)
29
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.,
(Source: Taylor, 2008)
30
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)
(Source: Taylor, 2008)
31
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
(Source: Taylor, 2008)
32
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
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
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
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
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
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
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
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?
(Source: Taylor, 2008)
40
 Communication at its best
https://www.youtube.com/watch?v=3AS8lGN9-KU
(Source: Taylor, 2008)
41
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
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
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
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
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 (3rd ed.).
American Journal of Occupational Therapy, 68(Supp.1), S1-S48.
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

similar documents