Abstract
The findings from this study suggest that therapeutic communication may be perceived differently by clients and therapists, highlighting the importance of therapists’ communicative self-awareness and a need for strategies to clarify their intentions and clients’ experiences.
Occupational therapists’ use of self in therapeutic relationships is considered critical to the therapy process (American Occupational Therapy Association, 2014) because of its utility in influencing outcomes (Seymour, 2012; Taylor et al., 2009). Therapists have repeatedly identified the use of self and partnership with clients as two key values (Drolet & Désormeaux-Moreau, 2016; Taylor et al., 2009). Perhaps most important, the therapeutic use of self is valued by clients (D’Cruz et al., 2016; Peoples et al., 2011). Determining what makes use of self therapeutic is no easy task. Each client has unique communication needs and preferences (Peoples et al., 2011), and any particular strategy “may be perceived differently depending on the client group” (Holmqvist et al., 2013). Therefore, it is important that health care professionals custom tailor their approach to therapeutic relationships.
Taylor’s (2020) intentional relationship model (IRM) provides a framework for this customization in that it integrates research on the use of self in occupational therapy and offers a vocabulary with which to understand and improve therapists’ communication (Solman & Clouston, 2016). The IRM features six therapeutic communication modes: (1) advocating, (2) collaborating, (3) empathizing, (4) encouraging, (5) instructing, and (6) problem solving. The use of these modes varies according to clients’ needs and preferences; therapists’ personality, training, experience level, and mood; requirements of the activity at hand; workplace and personal cultures; time constraints; and the degree of comfort and familiarity the client and therapist have in their relationship, among other variables (Taylor, 2020). Although research suggests these modes vary in frequency of application (Taylor et al., 2011), all are considered equally valuable when used with skill in appropriate contexts (Taylor, 2020).
Unfortunately, the suboptimal use of communication modes may contradict the values of occupational therapy and result in negative interactions (Taylor, 2020). Evidence of discrepancies between therapists’ values and practice exists (Mulligan et al., 2014), as do clients’ accounts of disrespect and disempowerment in therapy (D’Cruz et al., 2016; Peoples et al., 2011). Research is needed to illuminate potential differences in therapists’ and clients’ perceptions of mode use to prevent negative consequences. The current study hypothesized that discrepancies exist in clients’ and therapists’ perspectives of communication mode use. We tested these hypotheses using a theory-based, validated assessment tool known as the Clinical Assessment of Modes (CAM; Fan & Taylor, 2016).
Method
This study had an observational, cross-sectional design and was approved by the institutional review board at a large urban university. Participants were recruited from inpatient and outpatient units at the university-associated hospital over the course of 9 mo. Written consent was collected before data were collected. The participants were clients and therapists, paired in dyads. The client inclusion criteria included being (1) an inpatient or outpatient, (2) age 18 or older, (3) medically stable, (4) able to read and respond to the study questionnaire, (5) in the beginning of their current rehabilitation program at the study hospital, and (6) scheduled for at least three sessions with their assigned therapist. Therapist participants included occupational, physical, and speech therapists working in the study hospital’s inpatient and outpatient rehabilitation units. Clients were paired with the direct treating therapist who had been assigned to them after the clients consented to participate. Each client and their assigned therapist completed the study questionnaire about their sessions together, immediately after that client’s third treatment session. Clients and therapists were instructed to evaluate the therapist’s communication on the basis of the third treatment session only.
Measures
The CAM is a set of questionnaires that assesses the use of six therapeutic communication modes described in Taylor’s (2020) IRM (i.e., advocating, collaborating, empathizing, encouraging, instructing, and problem solving). The Therapist Self-Report Version (CAM–T; Taylor et al., 2013) and the Client Time 2 version (Taylor & Fan, 2015) were used to gauge perceptions of the therapists’ use of these modes. The 30 items of both versions are identical, except for wording to identify the respondent as client or therapist. Research suggests that the CAM–T is reliable and valid in rehabilitation settings (Taylor & Popova, 2020).
The CAM features a unique five-item subdomain for each mode. Each item gauges the use of a specific communication behavior associated with one mode and is scored on a Likert scale ranging from 1 (never) to 5 (very frequently). For example, the item “We talked about legal rights for people with disabilities” assesses the advocating mode. The items do not require knowledge of communication modes or IRM theory to complete. Item scores within each subdomain are averaged; a higher subdomain score indicates a perception that the associated mode was used more frequently. Research suggests that each mode’s CAM subdomain describes a distinct, unidimensional construct (Fan & Taylor, 2016).
Analysis
Because of subjectivity in respondent perceptions, there is no preexisting item hierarchy in the CAM. Therefore, we used Rasch analysis to generate an order of likelihood of endorsement of each item along a continuum, thus creating the item hierarchy for clients’ and therapists’ responses. Items easily endorsed by clients or therapists were more frequently perceived by clients or self-identified by therapists. Items with a lower probability of being endorsed were perceived and self-identified less often. Two facets (person and item) were used; no variables were anchored. Client–therapist mode perception differences were also analyzed with an independent-samples t test. Statistical analyses were completed with IBM SPSS Statistics (Version 19.0) and Facets (Version 3.86.1; Linacre, 2011). A significance level of .05 was implemented.
Results
Participants
One hundred twenty clients consented to participate in this study; 9 of these were discharged before the third session and were thus unable to complete the questionnaire. One withdrew from the study, making the attrition rate 8.3%. Participating clients (n = 110, 50.9% women) were ages 18 to 89 yr (M = 50.1, SD = 15.5). Most were diagnosed with stroke (15.5%) or fracture (14.5%). Clients were seen in inpatient (57.3%) and outpatient (42.7%) rehabilitation settings. Further client demographics are shown in Table 1.
Client Demographics
Note. n = 110. CTS = carpal tunnel syndrome; HS = high school; SCI = spinal cord injury; TBI = traumatic brain injury.
Inpatient and outpatient data were combined for analyses. A χ2 test to assess potential differences between inpatients’ and outpatients’ demographics revealed no significant differences between groups in regard to marital status (χ2 = 4.29, p = .368) or education (χ2 = 4.29, p = .369). Likewise, a two-tailed Fisher’s exact test found no significant differences between groups’ distributions of sex (p = .254). A Levene’s test for equality of variances assumed equal variances for inpatients and outpatients in terms of age, F(108) = 1.037, p = .311, but the associated independent-samples t test to check interval data revealed a significant difference between the mean age of inpatients and outpatients, t(108) = 3.633, p < .001.
Participating clinicians (n = 38, 71.1% women) were ages 21 to 52 yr (M = 32.5, SD = 11.0). Clinicians were physical (n = 24), occupational (n = 13), and speech therapists (n = 1). Further therapist demographics are presented in Table 2.
Therapist Demographics
Note. n = 38.
Comparison of Mode Use From Client and Therapist Perspectives
Table 3 shows the CAM items ordered from those perceived least to most often by clients and therapist, using Rasch analysis. The five least frequently identified items were identical for both groups: Four were from the advocating mode, and the fifth was from the empathizing mode. Two of the five most frequently identified items were common to clients and therapists: (1) “Listened to this client with true interest” (empathizing) and (2) “Explained what was happening or told this client what would happen next” (instructing). The groups’ other most frequently identified items differed. Clients experienced therapists as using the instructing mode most often, accounting for three of their five most frequently identified items, and therapists reported using the empathizing mode most often, accounting for four of their most frequently identified items.
Paraphrased Item Hierarchy From Clients’ and Therapists’ Perspectives
Note. Items increase in frequency from the top of the table to the bottom, from least identified to most identified. The 20 middle items are not displayed. Items describe therapists’ behavior and are paraphrased for brevity. A = advocating; C = collaborating; CAM–C2 = Clinical Assessment of Modes–Client Time 2: Communicating with Your Therapist; CAM–T = Clinical Assessment of Modes–Therapist Version; Em = empathizing; I = instructing.
An independent-samples t test (Table 4) compared clients’ and therapists’ mean CAM subdomain scores within each mode. The mean empathizing subdomain score did not significantly differ between clients and therapists (p = .130), but the groups’ subdomain means significantly differed in regard to the advocating (p < .001), collaborating (p < .001), encouraging (p < .001), instructing (p < .001), and problem-solving (p < .001) modes.
Independent-Samples t Test of the CAM–C2 and CAM–T
Note. CAM–C2 = Clinical Assessment of Modes–Client Time 2: Communicating with Your Therapist; CAM–T = Clinical Assessment of Modes–Therapist Version; df = degree of freedom.
* p < .05, two-tailed.
Discussion
The current study identified differences in client and therapist perspectives of therapists’ communication, as measured by the CAM. The CAM results can be used to assess, from the clients’ and therapists’ perspectives, which modes and specific mode-associated communication behaviors therapists used most and least often. Differences were observed in average scores for all modes except empathizing. A Rasch analysis revealed a consensus on the CAM items therapists used least often; these were mostly from the advocating mode. Clients’ and therapists’ perspectives on therapists’ most frequently used modes differed: Clients perceived that therapists used more instructing behaviors, and therapists perceived that they used more empathizing behaviors.
There are several reasons why such differences were observed. First, clients’ expectations for therapy may influence their perceptions of what actually occurs (Eastwood et al., 2019). Second, therapists’ client- centered values may influence them, consciously or not, to perceive themselves as using modes that appear sensitive to client needs, such as empathizing; occupational therapists have previously reported values that differ from their actual practice (Mulligan et al., 2014). Third, therapists may apply a mode unsuccessfully, such that clients may perceive the use of a different mode altogether; the IRM identifies this as suboptimal mode use (Taylor, 2020).
Regardless of their cause, discrepancies in understanding warrant concern because poor communication is associated with reduced client satisfaction (Ng & Luk, 2019), worse outcomes (Taylor et al., 2009), and medical error (Clark et al., 2013). The findings from this study suggest that such discrepancies may occur in rehabilitation therapy, emphasizing the importance of therapists’ communicative self-awareness as well as a need for strategies to clarify therapists’ intentions and clients’ experiences.
Limitations
Limitations should be considered when generalizing the results of this study. First, as volunteers, the participants may have anticipated or perceived more positive communication. Despite confidentiality assurances, social desirability response bias potentially remained. Also, therapists’ communication may vary by discipline, the nature of their job, or their academic training.
Recommendations for Practice
Clinicians can use the CAM item responses to initiate early conversations between clients and therapists to communicate rehabilitation expectations and clarify communication. These factors have been associated with improved client satisfaction and outcomes (Eastwood et al., 2019). Also, therapists’ intentional education, self-reflection, and practice with communication modes will help them develop the IRM’s notion of therapeutic style (Taylor, 2020). Clinicians with a developed therapeutic style may gravitate toward their “natural” modes (i.e., those that are consistent with their personalities), but expert communicators apply all six modes skillfully to respond to clients’ situational needs. Therapists are encouraged to develop the critical self-awareness and interpersonal self-discipline needed to flexibly apply modes that appropriately facilitate each interaction and reduce misunderstandings in communicating with clients. With ample experience and practice, therapists can become aware of the various therapeutic communication types and be well prepared to understand clients’ needs and expectations.
Recommendations for Future Research
This study assessed communication at a single time point. Future longitudinal research may identify how perceptions change as therapeutic relationships develop and clients move through the care continuum. Likewise, therapists’ mode use may develop as they gain experience (Taylor, 2020). Most therapists in this study were entry-level clinicians; additional research is needed to compare the communication of experienced and entry-level therapists. Studies that examine communication across settings or disciplines may clarify the uniqueness of occupational therapy practitioners’ communication across various contexts. Researchers may also explore whether the use of the advocating mode—to which, in the current study, the least frequently identified CAM items belonged—is universally low or increases in other settings and as clients approach discharge. Finally, an examination of the match between clients’ communication preferences and their actual experiences may shed light on satisfaction, a quality indicator.
Implications for Occupational Therapy Practice
This study has several implications for occupational therapy practice: The CAM is useful in quantifying therapeutic communication in rehabilitation and may verify whether clients’ perceptions match therapists’ intended mode use. The IRM emphasizes that clients’ experiences determine communication effectiveness; our findings highlight a need for dialogue to clarify these experiences. Clinicians’ development of a flexible therapeutic style, congruent with their personality and their clients’ needs, is encouraged to reduce the potential for miscommunication.
Conclusion
In this study, we used a validated assessment, the CAM, to measure perceptions of therapists’ communication as described by the IRM; perceptions differed between clients and therapists. Clients experienced therapists as instructing more; therapists reported themselves as empathizing more. The CAM helped identify perception discrepancies, thus providing a foundation for evaluating and discussing therapists’ interpersonal mode use.
Footnotes
Acknowledgments
The authors extend their gratitude to the clinical therapists and clients who were involved in this study.