THERAPEUTIC USE OF SELF

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“The use of oneself in such a way that one becomes an effective tool in the evaluation and intervention process.”

Therapeutic Use of Self refers to an OT practitioner’s planned and conscious use of themselves as part of the therapeutic process to optimize patient interactions. The assumption is that the OT practitioner can influence the outcome with the use of their own personality, perceptions, opinions, and judgments. By focusing on the patient-therapist relationship, the OT practitioner is more likely to understand the patient’s experience as an individual with a disability, and jointly formulate an intervention plan that centers on the patient’s goals. When a viable therapeutic relationship is formed, practice is much more likely to be client-centered.

Utilizing these intentional techniques helps the therapeutic relationship and establishes:
• A healthy, professional relationship
• Promotion of participation in occupational therapy services
• Ways to guide the patients towards meeting their chosen occupational goals.

style=”color: #000000; font-size: 12pt;”>The relationship between the OT practitioner and the patient is an important part of the therapeutic process, from first meeting a person who has been newly referred, through coping together with the successes and setbacks of the intervention process, to ending the relationship on a positive note. Ideally, the therapeutic relationship is a partnership or collaboration between OT practitioner and the patient, in which the goals and methods of intervention are negotiated throughout the process. If an individual is unable to take a full part in negotiating the process, because of illness or disability, the OT practitioner has a responsibility to facilitate their involvement as far as possible and to protect their interests to the best of the occupational OT practitioner’s ability.

The OT practitioner uses interpersonal skills to deal with a whole range of needs, such as engaging the initial interest of someone with a volitional disorder, supporting a bereaved person through the grieving process, helping someone to express difficult feelings appropriately, valuing a person with chronic low self-esteem and helping carers to work out how best to balance their own needs with their caring role. These interpersonal skills can be the most valuable resource in an intervention.

Mosey’s 11 Elements that Help the OT Practitioner Relate to the Patient
Mosey (1986) identified 11 elements that contribute to the OT practitioner’s ability to relate effectively to the people they work with:

1. A perception of individuality – recognition of each person as a unique whole

2. Respect for the dignity and rights of each individual

3. Empathy – ability to enter into the experience of another person without losing objectivity

4. Compassion or sympathy – willingness to engage with another person’s suffering

5. Humility – recognition of the limits of one’s own knowledge and skill

6. Unconditional positive regard – concern for the individual without moral judgements on their thoughts and actions

7. Honesty – telling the truth to the people they work with; this is an aspect of being respectful

8. A relaxed manner

9. Flexibility – ability to modify own actions to meet the demands of a situation

10. Self-awareness – ability to reflect on one’s own reactions to the world and on the effect one is having on the world in any given situation

11. Humor – a lightness of approach which, used appropriately, can facilitate the therapeutic process.

6 Modes of Therapeutic Use of Self
The six modes of the therapeutic use of self, based on the Intentional Relationship Model (Taylor et al., 2009), are as follows:

1. Advocating
Standing up for the patient and providing them with additional resources to enhance the therapeutic process.
Examples:
• 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 patient to return to work

2. Collaborating
Including the patient in every aspect of planning and carrying out the therapeutic process.
Examples:
• Develops goals and strategies with patient
• Modifies intervention plan based upon patient’s input

3. Empathizing
Understanding the patient’s internal, emotional experiences during the therapeutic process.
Examples:
• Actively listens to patient’s story
• Adjusts intervention session to meet patient’s needs

4. Encouraging
“Cheerleading” or urging the patient to participate and progress.
Examples:
• Suggests that the patient “do one more repetition”
• Provides positive reinforcement

5. Instructing
Taking on a teacher role to educate the patient.
Examples:
• Teaches the patient to dress using one hand
• Reviews precautions for the condition
• Demonstrates use of adaptive equipment or technology

6. Problem-solving
Working with the patient to reason through and analyze complex therapeutic situations.
Examples:
• Figures out with patient how to perform daily living skills
• Examines with patient how to access resources
• Modifies equipment to meet the patient’s needs

According to the assumptions of the Intentional Relationship Model (Taylor, R. R. 2008), not one single mode is more important or essential than the other. Additionally, the therapist learns to strategically juggle and apply each mode to influence the route of the therapeutic process for the patient to succeed.

2 Basic Principles of Therapeutic Use of Self

1. OT practitioners must possess a level of self-awareness so that they can mindfully examine their role in the intervention process.

2. OT practitioners learn to develop trust, provide support, actively listen, and empathize. They use genuineness, respect, self-disclosure, trust, and warmth when interacting with clients.
These qualities are useful in establishing and sustaining therapeutic relationships.

Techniques to Develop Trust
• Follow through with plans.
• Be on time to appointments with patients.
• Be honest with patients.
• Do not overpromise things you cannot deliver.
• Be cautious when disclosing personal information.
• Discuss patients’ progress and intervention plans in private.
• Always involve the patient in decisions.
• Be direct upon decisions.
• Use clear language so the patient understands.
• Address any issues or problems that develop in the therapeutic relationship.
• Remember to put the patient first.

4 Techniques that can Enhance the Therapeutic Use of Self

1. Attunement
Attunement is the ability to be completely present with the patient, developing a feeling of connectedness with them. Within attunement you should be considering what your body language is saying, how your tone of voice is delivering the message, if your facial expressions and body language (including eye contact) match what you are saying and if you need to mirror the patient in order for them to recognize that they have your full attention.

2. Providing the patient with unconditional positive regard.
Unconditional positive regard is the ability to accept that the patient is trying their best and accepting where they are at that time. This does not mean you have to agree with their choices or even like them as a person. However, it does mean that you are providing patient-centred care and treatment – whilst allowing the patient to make mistakes, through their ability to make their own self-determined choices.

3. Self-disclosure
Self-disclosure can be a positive experience for the patient, building rapport with them and developing a therapeutic alliance.
There are two types of self-disclosure; intra-session disclosure and extra-session disclosure.
Intra-session disclosure refers to reflecting how something they have done or has happened during the session has made you feel.
Extra-session disclosure is disclosing information about yourself, whether that be previous qualifications, family life or interests and events.

There are five golden rules to self-disclosure:
1. Waiting
2. Being brief
3. Being clear that this is your opinion
4. Considering the patient’s values
5. Considering the impact self-disclosure is going to have

Waiting refers to the therapist considering why they are self-disclosing, whilst being brief is to ensure the patient does not feel the therapist is hijacking their session. OT practitioners also need to ensure that when they are self-disclosing the patient knows this is their opinion and is not part of their clinical expertise or experience, as the statement could be contrary to the patient’s own beliefs and values. Additionally, if the statement is contrary to the patient’s own beliefs and values, consider if this self-disclosure is going to jeopardize the therapeutic relationship and alienate the patient? This then leads to the final factor of considering the impact that self-disclosure can have, as patients may be left feeling burdened by the self-disclosure rather than aligned with the OT practitioner. Whilst these ‘golden rules’ ensure self-disclosure is used appropriately, it is important to remember that it can assist the patient with humanizing the therapist.

4. Balance the Power Differential
Patients often believe that the OT practitioner has greater power than them. However, this belief can lead to self-helplessness, whereas an OT practitioner should be promoting self-empowerment and self-help. Therefore, it is essential to understand the patient’s background and culture, whilst presenting yourself in an honest way. That means the power imbalance should be addressed during therapy or care. The acknowledgement that you may know more about a particular solution to their problem based on your training and experience should be made, whist acknowledging that they are the expert about themselves, their culture, their expectations and their own lives. The patient and the OT practitioner should then be working together to problem solve how the solution that the therapist suggests can be integrated into the patient’s life, based on the information the patient has about themselves.

An OT practitioner who successfully uses therapeutic use of self for intervention as having the qualities or attributes of showing empathy (including sensitivity to the patient’s disability, age, gender, religion, socioeconomic status, education, and cultural background), being self-reflective and self-aware, and being able to communicate effectively using active listening and consistently keeping a patient-centered perspective that in turn engenders an atmosphere of trust. The very focus of the occupational therapy process provides a favorable context to support the OT’s use of therapeutic use of self as intervention. By using a patient-centered approach and beginning the process with an evaluation that seeks information about the patient’s occupational history and occupational preferences, the therapist’s initial interactions with the patient are characterized to the patient as being interested in what the patient does (occupational performance), who the patient is (contexts and environments, and patient factors such as values, beliefs and spirituality), and what occupations give meaning to the patient’s life.

References:
– Creek’s Occupational Therapy and Mental Health, 6th Edition
– Pedretti’s Occupational Therapy – E-Book: Practice Skills for Physical Dysfunction (Occupational Therapy Skills for Physical Dysfunction (Pedretti)
– https://otflourish.com/therapeutic-use-of-self-occupational-therapy
– https://nursekey.com/therapeutic-relationships-2/
– https://www.theothub.com/article/therapeutic-use-of-self