Use of Self
By Claudia Stahl
INTRINSIC MOTIVATION. SELF DIRECTION. THE ABILITY to affect one's own state of health.
Do these terms sound familiar? Are they part of OT?
According to Marilyn B. Cole, MS, OTR/L, these key concepts of humanistic theory are as deeply rooted in occupational therapy practice as the Model of Human Occupation and SI. Most closely associated with the theories of Carl Rogers and Abraham Maslow, who are also referred to as "meaning-in-experience" therapists, the humanist philosophy is a holistic one: each person is an intricate marriage of mind, body and spirit.
As such, it surprised Cole when, at a conference roundtable she moderated "Whatever Happened to the Therapeutic Relationship?" some therapists questioned the place of psychology theories like those of Rogers and Maslow in the practice of OT. Cole believes that keeping out the psych component of OT practice means disowning the fundamental beliefs of OT founders like Adolf Meyer, who recognized the integral relationship between biological, psychological and social/cultural influences in an individual's overall health.
What Cole calls the therapeutic relationship has been referred to as "therapeutic use of self" and "therapeutic alliance." Although these models are an endangered species in a reductionistic health care system, they are not extinct. "Therapeutic relationship is still alive, but we're calling it something else. We're saying we need to pay attention to the human spirit--who the person is inside, apart from his or her disability. It is the concept that the core of the patient doesn't change when he or she becomes disabled," Cole explained.
"But (often) the disability...gets treated and the person gets lost; that's what we don't want to do and why we need the therapeutic relationship," she said.
Cole teaches sophomore and junior occupational therapy students at Quinnipiac College in Hamden, CT, to integrate the humanistic frame of reference into their interviewing technique. Adopting a person-centered approach, students learn to relinquish most of the control in therapy to the patient through unconditional positive regard (acceptance of client's feelings and actions) and empathy--communication to the patient that the therapist understands what he/she feels and how behavior is attached to the feeling.
"We need to develop a relationship with patients in order to effectively treat them, and that means that we need to see the world from the patient's point of view. You can't do that without a basic sense of empathy," said Cole.
Students are taught skills of concreteness (getting patients to define their needs or problems), immediacy (direct discussion of their relationship with the patient), confrontation (pointing out discrepancies in what patients are saying and their actual behaviors), and self disclosure (using personal experiences appropriately to establish rapport or to guide behaviors and responses). Students practice these skills in role playing exercises.
While empathy is often thought of as something innate, Cole says it can be taught. It begins with a genuine respect for the patient. Students who exercise that respect and recognize that there is something within themselves that they share with every patient, are the most skilled at getting to the heart (or spirit) of the patient. Who has time to provide this level of therapy in managed care? Everyone, Cole says. It just takes a little creativity: put some questions in writing and give them to the patient to answer at another time; find out what you can about the patient by collaborating with other team members; interview other people in the patient's life, if applicable, about the patient's social roles and environment; use chats with patients during therapy to learn more about their needs, roles and personality.
Cole says educators who fail to teach therapeutic relationship are risking the future of the profession.
"The therapeutic relationship should guide treatment, rather than the other way around," said Cole.
Claudia Stahl is an ADVANCE associate editor.