Occupational therapy and the therapeutic use of self

Introduction

The therapeutic use of self describes a concept considered integral to the process and outcomes of occupational therapy practice (Taylor and Melton, 2009). Yet despite the occupational therapy literature reflecting this importance, the concept is also considered one of the less understood facets of practice (Taylor et al., 2009). There are no shortages of definitions attempting to delineate the use of self; however, the frequently quoted definition by Punwar and Peloquin (2000: 285) offers a useful starting point, describing the therapeutic use of self as: “A practitioner's planned use of his or her personality, insights, perceptions and judgements, as part of the therapeutic process.” This builds upon the earlier work of Mosey (1986), who identified the deliberate adaption of one’s responses in order to enhance and maximise the therapeutic encounter. These definitions offer a level of tangibility to the idea of the therapeutic use of self, yet offer little to guide practitioners in what it actually means to enact the use of self within everyday practice; consequently, it remains a rather liminal concept.

Given that the notion of the therapeutic use of self is derived from the field of counselling and psychotherapy (Stickley and Freshwater, 2002), and is also considered fundamental to the practice of other professions (Freshwater, 2002), finding the language that describes most accurately what it represents within occupational therapy specifically, could be a key step toward greater cohesion and understanding of the topic. Notably, amongst more current definitions, Seymour (2012) does link the use of self directly to occupational outcomes. However, we suggest it is time to make this occupational lens far more overt and embedded into professional discourse. Moreover, whilst current research on the use of self in occupational therapy does exist, there is an observable predominance found in North American literature, thus mirroring that specific cultural context. Consequently, in order to develop a more nuanced understanding of the use of self within the United Kingdom (UK) milieu, it would be beneficial to research this in both educational and practice settings, comparing and contrasting these with wider international findings on the subject. In the context of a cost-driven and change orientated health and social care climate, where professionals are more accountable than ever for evidencing their distinct contribution to service delivery and client experience, it would appear both timely and advantageous to review this long accepted, yet little questioned aspect of our profession.

Exploring the therapeutic use of self in discourse, education and practice

There are illuminating examples within the literature that demonstrate the perceived value and essential nature of the therapeutic use of self to the practice of occupational therapy, specifically a positive link between the role of the use of self in therapeutic efficacy and client involvement.

An American survey by Cole and McLean (2003: 41), who sampled 129 occupational therapists, found that 96.5% deemed that ‘therapeutic relationships are critical to functional performance’. Similarly, in the context of the United States, Taylor et al. (2009: 202) questioned 568 occupational therapists and found more than 80% believed the “therapeutic use of self was the most important skill in their practice”, whilst more than 90% perceived a direct link between the therapeutic relationship and subsequent occupational engagement of the client. A comparable UK survey cited by Taylor and Melton (2009) identified that 83% of respondents placed considerable value on the use of self, with 72% perceiving it to be a primary influence of therapy. This is a valuable study from the UK perspective; however, the original source could not be located and, as previously noted, there is a paucity of such research in the UK; thus, the following discussion utilises evidence that is predominantly American in origin.

In terms of education and practice skills, Taylor et al. (2009) also established that half of the respondents in their survey felt that their professional education provided satisfactory preparation in utilising the use of self as a therapeutic tool, with less than 5% receiving any training specifically on the topic and less than 10% reporting any professional development opportunities in relation to the use of self once in practice. Interestingly, Davidson (2011: 97) examined how the use of self is taught in university education, and identified that whilst aspects of the use of self were consistently included in the curricula, instructional content was weighted in favour of ‘the more pleasant, client-congruent topics’, whilst those that were more challenging to encounter or enact, for example, setting boundaries, dealing with coercion, aggression, or sharing bad news, were frequently neglected or absent. In terms of the drive for client centred care in the UK health and social care settings, this is a significant omission, which, if addressed could facilitate a far more positive experience for both client and therapist. Thus, if both theory and practical skills pertaining to the use of self were clearly and comprehensively integrated into both undergraduate and postgraduate training and education, so the space could exist to synthesise these important skills and enhance and, critically, elucidate a common language and benchmark for practice.

The intentional relationship model (IRM)

The intentional relationship model (IRM) (Taylor, 2008) is a noteworthy development in occupational therapy literature addressing just this point. Designed to complement and be used in conjunction with existing models of practice, its core focus is the development and management of skills to facilitate the interpersonal side of the occupational therapy process (Taylor, 2008). What distinguishes the IRM from previous literature on the therapeutic use of self in occupational therapy is its aim to give substance to this aspect of our knowledge base by offering a clear conceptual framework for understanding the use of self, combined with detailed practical tools and techniques for practitioners to navigate their role within the therapeutic relationship. Essentially, Taylor (2008) purports the development of six key interpersonal skills or ‘modes’ of practice, identified as the ability to flexibly apply the skills of advocating, collaborating, empathising, encouraging, instructing or problem-solving with the client at the appropriate time and dependent on need.

Although the IRM represents an important development, Taylor et al. (2011) discovered that whilst occupational therapists did adapt their mode use in response to perceived therapeutic needs, there was in fact, a tendency to remain generally consistent in the application of modes across client populations, thus challenging the concept of flexibility purported in the IRM (Taylor, 2008). Both Taylor et al. (2011) and Bonsaksen (2013) suggest that this limited application of flexibility could be addressed by offering both undergraduate and postgraduate learning opportunities on the use of flexible mode use in practice. The notion is supported by Gorenberg (2013), who utilised the IRM to develop an intensive professional education workshop on the therapeutic use of self; this evidenced not only gains in knowledge and skills, but enabled participants to work more effectively with clients they had previously identified as ‘interpersonally challenging’ (Gorenberg, 2013: 396). This clearly suggests that the IRM is effective in assisting occupational therapists to manage perceived difficulties in interpersonal practice and to improve both the client and therapist experience.

Whilst the application of the model requires further research, nascent conclusions suggest that potential exists for the IRM to help bridge the theory–practice gap, by embedding the explicit inclusion of the therapeutic use of self in both undergraduate and postgraduate occupational therapy education and providing a framework to understand and enact the therapeutic use of self in the client–therapist encounter. Thus by exploring the implementation of this model or developing other methods to promote the therapeutic use of self in education and practice arenas, so we may enhance client engagement and improve efficacy within practice.

To summarise, these findings provide a flavour of the discord between theory and practice in relation to the therapeutic use of self, identifying that whilst the use of self may be a “universally held value” within occupational therapy (Davidson, 2011: 89) without a shared lexicon to communicate it, and a paucity of focused and comprehensive education to assure mastery in practice, there is little evidence to sustain this claim. It is worth noting at this point that the American Occupational Therapy Association (2014), expressly names the therapeutic use of self as a distinct professional aptitude in its documentation. Alternatively, the College of Occupational Therapists makes no direct reference but does refer to the responsibility to ‘foster appropriate therapeutic relationships’ (2015: 29). Moreover, the regulatory body, the Health and Care Professions Council (2013), elaborates that a therapist must demonstrate effective verbal and non-verbal communication skills, understanding the impact of such skills upon the therapeutic process and be able to move between different means of communication, adapting in response to the client’s needs and characteristics. Arguably, all such requirements and guidance are pertinent to enacting the therapeutic use of self within practice but if the UK standards were to adopt a more direct reference, this could form a significant move in disseminating the worth and value of the therapeutic use of self as a concept, fostering its integration into the everyday language of practice.

Conclusion

This opinion piece has discussed the perceived value of the therapeutic use of self to client participation and the efficacy of occupational therapy, and juxtaposed this with the apparent discrepancy between theory and practice in this area. We have argued that if the therapeutic use of self was given greater attention within the profession’s education and practice, so we could begin to address this gap, and have posited that the IRM (Taylor, 2008) may offer a tool to facilitate this. However, we have also noted the paucity of research and a shared vision on the subject from a UK perspective, suggesting that addressing this is critical in the present UK educational and health and social care milieu. In the interim, on an individual level, the possibility remains for practitioners to commit to developing their own therapeutic use of self, acknowledging in this undertaking, the role of both ‘art and skill’ (Currid and Pennington, 2010: 40).

Research

Ethics approval was not required for this opinion piece.