Abstract
Developing a therapeutic client–therapist relationship is believed to be critical to facilitating the occupational therapy process and ensuring positive client outcomes (Cole & McLean, 2003; Palmadottir, 2006; Taylor et al., 2009). It has been suggested that at the core of an effective therapeutic relationship is authentic and respectful interpersonal communication with clients (Cole & McLean, 2003; Palmadottir, 2006; Punwar & Peloquin, 2000; Taylor, 2008). Taylor (2008) developed the Intentional Relationship Model (IRM) to characterize therapeutic communication and the therapeutic relationship in occupational therapy. Research suggests that the IRM captures these processes well in the Western context (Fan, 2014; Taylor et al., 2011). However, its applicability in occupational therapy across different sociocultural contexts is poorly understood.
Because it is well recognized that communication styles differ across sociocultural contexts, it is important to examine the relevance of the IRM in differing contexts. We examined the therapeutic communication and therapeutic relationships of occupational therapists in two different sociocultural contexts: the United States and Singapore.
Intentional Relationship Model
Taylor (2008) developed the IRM in response to a need in the occupational therapy profession for an explicit, integrated approach to understanding therapeutic communication and the therapeutic relationship within the occupational therapy process. The IRM has four main attributes: (1) the client, (2) the practitioner, (3) the interpersonal events that inevitably occur during therapy, and (4) occupation. Within the model, Taylor described therapeutic modes as interpersonal communication styles that include the practitioner’s verbal and nonverbal ways of relating to a client. Six therapeutic modes were identified in the IRM (in no order of preference):
Advocating: facilitating environmental access, negotiating environmental barriers, reinforcing the client’s positive identity
Collaborating: facilitating an active partnership with the client, supporting the client’s preferences in decision making
Empathizing: striving to understand the client’s thoughts and feelings, validating the client’s experience in a nonjudgmental way
Encouraging: instilling hope, providing positive reinforcement, facilitating with fun and humor
Instructing: providing information, setting structure and limits, engaging in direct teaching of strategies and skills
Problem solving: facilitating the client’s reasoning through strategic questioning, helping the client consider different perspectives and solutions to problems.
These six therapeutic modes were initially derived from qualitative interviews with 12 occupational therapists, the majority of whom were from the United States, the United Kingdom, and South Africa (Taylor, 2008). Taylor (2008) reported that these modes can be highly therapeutic when used appropriately, or they can be nontherapeutic if overused, untimely, or used in an emotionally incongruent way.
Research on the IRM has focused on use of the therapeutic modes in practice. Five of the modes were examined through a national survey of U.S. occupational therapists reporting their general patterns of therapeutic mode use during therapy, not with respect to any particular client (Taylor et al., 2011). Patterns of mode use refers to the frequency with which therapists used particular modes in comparison with other modes. The 19-item survey developed for the study did not include the advocating mode; that mode was added later. The encouraging mode was found to be used the most and the empathizing mode the least; client diagnostic group did not appear to affect the patterns of mode use.
General preference for mode use was examined in 31 occupational therapy students in Norway (Bonsaksen, 2013). Data were collected using the Self-Assessment of Modes Questionnaire (SAMQ; Taylor, 2008, pp. 87–95), in which respondents rate their preferred mode use in 20 hypothetical vignettes. Problem solving was found to be the most preferred mode and advocating the least preferred. Subsequently, a larger study using the Norwegian version of the SAMQ (Bonsaksen et al., 2015) compared preferences for mode use between occupational therapy students and practicing occupational therapists in Norway (Carstensen & Bonsaksen, 2017). The students reported a higher preference for the advocating and instructing modes, whereas the therapists preferred the collaborating and empathizing modes. This finding suggests that mode use may differ by level of clinical experience.
Fan (2014) examined mode use as perceived by 38 rehabilitation therapists and their clients in the University of Illinois Hospital and Health Sciences System, a tertiary hospital in Chicago. Mode use was rated for a total of 110 unique client interactions after at least three sessions of therapy using matching versions of the Clinical Assessment of Modes questionnaires for clients (Taylor et al., 2013a) and therapists (CAM–T; Taylor et al., 2013b); these questionnaires were found to be valid and reliable (Fan, 2014; Fan & Taylor, 2016). Therapists reported using the empathizing mode the most, whereas clients reported experiencing the instructing mode the most. This finding suggests that mode use perception may differ even in the same interaction because of unknown factors (e.g., sociodemographic differences).
Different patterns of mode use were reported in each of these studies (Table 1), even when comparing samples of practicing occupational therapists (e.g., Taylor et al., 2011). Taylor et al.’s (2011) findings suggested that differences in mode use were not related to client diagnostic group, but it remains important to understand what factors do determine patterns and perceptions of mode use. The differences found between Norwegian students and therapists may reflect therapist experience and age as possible factors. The differences found between U.S. and Norwegian therapists and students suggest the possibility of sociocultural context as a factor. However, the U.S. and Norwegian samples also differed in terms of client diagnostic groups, age, and educational status, bringing into question possible interactions among these factors as well. The studies also varied in terms of measurement of mode use from preferred to actual use.
Patterns of Mode Use Across Different Studies
Note. — = not reported; CAM–T = therapist Clinical Assessment of Modes; SAMQ = Self-Assessment of Modes Questionnaire; SAMQ–N = Norwegian Self-Assessment of Modes Questionnaire; SD = standard deviation.
Because of these inconsistencies in the way mode use has been studied, it is unclear whether sociocultural factors affect perceptions and patterns of mode use. A broad literature indicates that sociocultural differences affect interpersonal communication and the development of the therapeutic relationship during therapy (Côté, 2013; Odawara, 2005; Seung, 2013). In addition, Iwama (2003) argued that contemporary occupational therapy has largely been based on Western cultural worldviews that do not accurately reflect occupational therapy practice from Eastern cultural perspectives. Therefore, in this study we undertook to compare IRM mode use in an Asian context (Singapore) to mode use in a Western (U.S.) context.
Singapore: An Asian Context
Singapore is characteristic of a modern metropolitan Asian city. Despite modernization and westernization of this urban city–state, where English is the first language, traditional collective core values are evident (Chang et al., 2003). For example, because filial piety is valued, families are traditionally expected to assume responsibility for care of injured or disabled persons (Kim et al., 2001), and a low proportion of people live alone (12.2%; Koh & Lee, 2014). Other traditional values of particular relevance to interpersonal behavior include maintaining interpersonal harmony, exercising emotional self-restraint, deferring to authority, and exhibiting high respect for people with specialized professional competence, such as health care professionals (Kim et al., 2001). These culture-specific values may influence interpersonal communication between clients and occupational therapists in Singapore.
Purpose of the Study
So far, no studies have been published on therapeutic mode use in an Asian occupational therapy context. The purpose of this study was twofold: (1) to examine similarities and differences in the patterns of actual therapeutic mode use as perceived by practicing occupational therapists in the United States and Singapore and (2) to examine sociodemographic factors that may contribute to differences in mode use between therapists in these two contexts.
Method
Study Design and Participants
Occupational therapists in both studies practiced in large tertiary hospital settings providing a comprehensive and specialized range of inpatient and outpatient services. We conducted a cross-sectional observational pilot study in Singapore to examine the patterns of IRM mode use identified by occupational therapists and clients and determine whether these patterns differed from those in a U.S. sample. Singaporean participants were recruited by convenience sampling from the National University Hospital. First, therapist participants were recruited from both inpatient and outpatient adult services if they had worked in the hospital for at least 6 mo in their specialty area. Clients of participating therapists were recruited if they were English or Mandarin speaking and age 21 yr or older and either were newly referred to occupational therapy and projected to complete at least three sessions or had already completed at least three sessions.
The U.S. data set was obtained from Fan’s (2014) dissertation study. Therapist participants included occupational therapists, physical therapists, and speech therapists. Client participants were subsequently recruited if they were English speaking, age 18 yr or older, newly referred for rehabilitation to any of the therapists who were initially recruited, and projected to compete at least three sessions of therapy. Deidentified data were extracted for 17 occupational therapists who rated interactions with 74 clients after at least three sessions of therapy.
Procedure
At recruitment, all occupational therapists and clients completed a sociodemographic questionnaire. After undergoing at least three sessions of occupational therapy together, therapists and clients completed the appropriate version of the Clinical Assessment of Modes questionnaire. The paper-and-pen questionnaire was completed immediately after the occupational therapy session, and therapists completed a separate questionnaire for each unique client–therapist interaction. The U.S. and Singapore studies were approved by the institutional review boards at the University of Illinois at Chicago and the National Health Group Review Board in Singapore, respectively.
Instrument
This article reports analysis of responses to the therapist version of the Clinical Assessment of Modes (Taylor et al., 2013b), a self-report questionnaire in which therapists rate the frequency of their use of the therapeutic modes on a 5-point scale (1 = never to 5 = very frequently). The questionnaire has 30 items in six subscales containing five items each. The six subscales reflect the six therapeutic modes in IRM. The CAM–T was reported to have acceptable validity and reliability in a tertiary acute setting (Fan & Taylor, 2016).
Data Analysis
All descriptive and inferential statistics were analyzed using IBM SPSS Statistics (Version 24.0; IBM Corp., Armonk, NY). Demographic data and CAM–T results were collected directly from the Singapore sample and extracted from Fan (2014) for the U.S. sample. χ2 tests of independence and t tests were used to compare categorical and continuous demographic variables, respectively. In the Singapore sample, age, sex, and educational status differed significantly between English- and Mandarin-speaking clients, but none of these variables was significantly related to CAM–T scores. Therefore, CAM–T ratings for both English- and Mandarin-speaking clients were combined in further analyses of the Singapore data.
To compare the patterns of mode use in the U.S. and Singapore samples, we calculated descriptive statistics and conducted independent sample t tests on raw and ranked scores. For mode subscores that were significantly different between the samples, general linear modeling was used to further examine possible predictors of mode use. To test possible predictors of mode use, full linear models were conducted with the covariates (i.e., study site, client diagnostic group, client educational status, therapist experience) and possible confounders (i.e., client age). The final model included only interactions that were significant and covariates that affected mode use.
Results
Demographic Data
Participant demographic data are presented in Table 2. The U.S. and Singaporean occupational therapists differed significantly in years of practice (χ2 = 15.83, p = .003) and type of occupational therapy degree (χ2 = 14.58, p = .002). No significant differences were found in age or gender. The U.S. and Singaporean clients differed significantly in educational status (χ2 = 35.63, p < .001), marital status (χ2 = 7.52, p = .023), occupational status (χ2 = 12.68, p = .005), and diagnostic group (χ2 = 10.89, p = .028).
Participant Demographics
Note. — = not reported; NA = not applicable; SD = standard deviation. Percentages take into account missing data.
Pattern of Mode Use
Seventeen U.S. and 18 Singaporean therapists rated frequency of mode use in interactions with 74 clients and 39 clients, respectively. Examination of item responses across modes revealed a response bias pattern (Furnham, 1986). Both samples of occupational therapists tended to avoid endorsing the lower frequencies of mode use (i.e., 1 = never and 2 = rarely). However, a larger proportion of U.S. (23.0%) than Singaporean (9.5%) therapists endorsed the highest frequency (i.e., 5 = very frequently). In addition, more Singaporean (25.1%) than U.S. (15.5%) therapists endorsed the midpoint frequency (i.e., 3 = occasionally). These findings suggest a response bias pattern indicating extreme responding in the U.S. sample and a moderacy bias in the Singaporean sample (Spencer-Rodgers et al., 2018).
To account for this possible bias, the CAM–T raw scores were converted to ranked data before the samples were further analyzed. The ranked data indicate that the pattern of mode use was similar in both samples (Table 3). With the exception of the instructing mode, the U.S. and Singaporean samples did not differ significantly in the frequency of mode use. Both raw and ranked scores indicated that instructing mode was used more frequently in the U.S. sample than in the Singaporean sample, t(111) = 3.33 and 2.16, p < .01 and .05, respectively.
Pattern of Mode Use by U.S. and Singaporean Occupational Therapists in Interactions With Clients
Note. For the U.S. sample, n = 74 therapist–client interactions. For the Singaporean sample, n = 39 therapist–client interactions.
Total possible raw scores range from 5 to 25 for each subscale.
Ranked scores range from 1 = most used to 6 = least used.
*p < .05. **p < .01.
Factors Associated With Mode Use
General linear modeling was used to predict use of the instructing mode on the basis of study site, client age, therapist years of practice, and client diagnostic group. Client education level was not significant and was removed from the final model. For completeness, general linear models were also examined for the other five modes (Table 4). Considering all other covariates, findings show that
U.S. occupational therapists reported higher use of the empathizing, encouraging, and instructing modes compared with Singaporean therapists.
Significant interaction effects between therapist experience and client diagnostic group were found for all modes except empathizing.
Therapists with experience of <1 yr (β = 3.73, p = .038, partial η2 = .056) or 1–5 yr (β = 4.72, p = .002, partial η2 = .121) reported higher use of the instructing mode compared with therapists with ≥6 yr of experience when interacting with clients with neurological conditions.
Summary of General Linear Models of Therapeutic Modes
*p < .05. **p < .01.
Discussion
Patterns of Mode Use
Use of all therapeutic modes was evident in both the Asian and U.S. contexts. Interestingly, the pattern of mode use was identical in the two contexts, with the instructing mode used the most and the advocating mode the least. These results differ from those of previous studies, in which U.S. occupational therapists reported using the encouraging mode the most (Taylor et al., 2011) and Norwegian occupational therapy students and practicing occupational therapists reported using the problem-solving mode the most (Bonsaksen, 2013; Carstensen & Bonsaksen, 2017). These differing patterns of mode use may reflect differences between actual therapeutic mode use in response to situational conditions in the clinical setting, measured in this study, and therapists’ general preferences and perceptions, measured in previous studies. Research on personal traits has similarly found that average personal behavioral tendencies may not be reflective of actual behavior in specific contexts because of the interplay of various situational factors (Cervone, 2005).
Cultural and Practice Settings
From a cultural perspective, one might expect the Singaporean occupational therapists to use the instructing mode more frequently than they did. Deference to authority, a generally accepted traditional Asian value, often results in power differentials between health professionals, who are respected authority figures, and patients (Kim et al., 2001; Schoen, 2005). In alignment with this value, it is expected that patients may prefer the health profession to provide expert advice and education, consistent with the communication elements in the instructing mode. Therefore, our finding that U.S. therapists used the instructing mode significantly more frequently was unexpected, given that the United States is considered to have a more individualistic culture. We would expect less power differential between health professional and patient in individualistic cultures, which may be reflected in communication styles that exhibit assertion of patient autonomy and opinion, such as the collaborating mode. However, this result is consistent with Fan’s (2014) finding that U.S. clients perceived the instructing mode to be used the most.
The high use of the empathizing and encouraging modes in both samples may indicate a pervasive occupational therapy culture leaning toward the Western value placed on individual thoughts and feelings (Hammell, 2009; Hopton & Stoneley, 2006; Iwama, 2003). It is possible that occupational therapists in both contexts are acculturated to these professional values through their educational programs and continued professional development.
This study suggests that practice setting may be a factor affecting mode use. Care in tertiary hospitals has evolved with increasing pressure to reduce length of stay and hasten discharge. Similarly, occupational therapists working in acute care have reported that the main aims of services are focused on discharge planning, education, and equipment provision, with limited time to carry out rehabilitation (Craig et al., 2004). These emphases may explain why the instructing mode was the most highly used mode overall in both study settings. However, the finding that the advocating mode was used the least was unexpected, considering that connecting clients with community resources is an expectation in discharge planning.
Therapist and Client Factors
Our findings suggest that depending on level of experience, occupational therapists tended to use different modes with clients in different diagnostic groups. This finding contrasts with the results of studies by Carstensen and Bonsaksen (2017), who found no association between therapist experience and preference for mode use, and Taylor and colleagues (2011), who found no differences in mode use among therapists practicing with different client diagnostic groups. However, both of these studies examined therapists’ general preferences and practices rather than actual client–therapist interactions.
Mattingly and Fleming (1994) noted that novice therapists tended to be more focused on the client’s diagnosis and medical procedures, relying primarily on procedural reasoning. Unsworth (2001) found that as occupational therapists became specialized in their area of practice, they tended to spend more time communicating with clients about their subjective illness experience and individualized context, relying more on interactive and conditional reasoning. Our findings support the assertion that therapists evolve in their interpersonal reasoning skills as they become more experienced and specialized in a particular area of practice.
Implications for Occupational Therapy Practice
The results of this study have the following implications for occupational therapy practice:
Cultural competence is an important aspect not only of clinical reasoning but also of interpersonal reasoning.
Although patterns of mode use appear to be similar across sociocultural contexts, therapists may adapt their mode use according to their experience and specialization.
Additional research is needed to further understand the client perspective and to ascertain whether clients perceive mode use as therapeutic and whether the therapeutic relationship is strengthened as a result.
Limitations of the Study
The main limitation of this study is the small sample size and convenience sampling. Cultural aspects and response biases should be considered in generalizing the results to occupational therapy practice in different contexts. All participants were volunteers, and they were not blinded to one another’s participation in the study. Further research is recommended with larger and more heterogeneous samples across additional cultural and practice sites to increase the generalizability of the results. In addition, research is needed that investigates therapeutic mode use from the client perspective. Ultimately, future research should examine the importance of therapeutic mode use in facilitating clients’ occupational engagement.
This study identified an apparent culture-specific response difference for the CAM–T. The greater tendency in the U.S. sample to endorse extreme responses may reflect the individualistic cultural context, which tends to place greater value on exerting personal opinion (Spencer-Rodgers et al., 2018). The lower tendency in the Singaporean sample to endorse extreme responses may reflect the collectivistic cultural context, with its relatively higher tendency toward uncertainty avoidance, desire to minimize personal risk, and preference for socially acceptable interactions (Spencer-Rodgers et al., 2018). Therefore, the moderacy bias, or the tendency to endorse midpoint responses, may be more apparent in Asian cultures such as that of Singapore. This pattern of response bias is an important consideration in survey development, implementation, and interpretation.
Conclusion
This study is the first to compare therapeutic mode use in different cultural settings. With the globalization of occupational therapy practice, it is important to engage in discussions about the generalizability of occupational therapy concepts. Further research is required to build the empirical evidence on therapeutic communication in different cultural and practice settings.
Footnotes
Acknowledgment
This research was conducted at the National University Hospital, Singapore, and the University of Illinois at Chicago. We thank the patients and therapists from the National University Hospital and the University of Illinois Hospital and Health Sciences System for their participation.