Interactive with Patients

Therapeutic Relationship

• Central aspect of the OT process.

• Catalyst for change in mental health recovery.

• Interactive process between tx and cx (two-way things).

• Requires interpersonal & communicative skills developed through reflective practice.

  • Knowing how to talk, to listen, read the room, and adjust to what the client needs.

• Degree of intimacy varies along a continuum based on:

  • Nature of the condition

  • Disruption to life and identity

  • Extent of recovery expected

  • Length and complexity of therapy

Emphatic Competence

• Emotional ability to accurately perceive and respond to cxs.

• Understanding the client’s lived experience.

  • Accurately perceiving their emotions

  • Picking with their verbal and non-verbal cues

• Fine-tuning the therapy process based on client responses.

• Essential for building trust and rapport

• Foundational skill for therapeutic use of self

Components of the Therapeutic Relationship

1. Phases of Developing Therapeutic Relationship

2. Stages of Therapeutic Process

Phases of Developing Therapeutic Relationship

• Phase 1: Developing Rapport

• Phase 2: Establish Trust

• Phase 3: Collaborative Partnership

• Phase 4: Sustain the Partnership

• Phase 5: Relationship Ensured

Phase 1: Developing Rapport

• Show respect and care.

• Listen and understand their story.

• Meet them at their comfort level.

• Show genuine interest.

• Initial connection that you build with the client

• Not limited to clinical details because we have to meet them where they are

• Adjust to their comfort level

  • Quiet → speak softly

    • Anxious → slow down

Phase 2: Establish Trust

• Spend time and listen.

• Give clear information.

• Show you understand their fears.

• Something to earn through consistency

• Explain OT in layman term (interpersonal skill)

• Unsure patient → give choices (sense of control)

• Worried/anxious patient → make them feel validate 

Phase 3: Working Together

• Equal partnership.

• Therapist brings expertise; client brings life knowledge.

• Set goals together.

• Try tasks to explore strengths and limits.

Phase 4: Enabling Occupational Performance

• Teach problem-solving.

• Encourage trying new things.

• Practice in realistic situations.

• Shift roles: guide →  supporter

• Go at their pace.

Phase 5: Achieving Outcomes

• Goals reached.

• Sense of control and confidence.

• Relationships and impact continue.

Components of Therapeutic Relationship

Therapeutic Communication

• Not limited to talking but it’s about verbal & non-verbal skills.

• Core Skill (improved through time through practice)

• The work of OT hinges on effective communication or exchange of thoughts and feelings between client and therapists.

• Verbal communication, nonverbal communication, therapeutic listening.

Verbal Communication

• Not limited to words you say but on HOW you will say it because it can calm or trigger them.

• Clear and audible in voice and mouth movements.

• Clear, brief, and accurate in terms of the content being transmitted.

• Emotionally modulated to match the situation, preference, and comfort level of the client.

• Confident in tone of voice about the content of what is being communicated.

  • Communicate at the level of the patient. 

• Professional, respectful, and tactful in terms of word choice.

  • Learn to stop when needed

  • Do not force the client to open

• Intentional about timing the relation between talking and doing.

• Talking with purpose and awareness.

Non-Verbal Communication

S — sit across the client squarely

O — open posture

L — leans slightly towards the other person

E — eye contact of approximately 50% OTT

R — relax

Therapeutic Listening

1. Empathic Learning

2. Guided Listening

3. Verbal Prompts and Sounds

4. Enrichment Questions

Empathic Learning

• Involves the process of recounting, accepting, and affirming any perception or experience a client offers (Gardner, 1991).

• Receiving and accepting w/o shaping or directing the answer of the patient.

Guided Listening

An alternative approach that involves a therapist’s attempts to shape what the client is saying by making one or more summary-type statements.

Verbal Prompts and Sounds

• Include expressions such as “Ah,” “Uh huh” or “Umm”. These utterances may be used to remind a client that you are listening, to highlight something.

• A client has just said, or encouraged a client to say more.

Enrichment Questions

• Gentle forms of inquiry designed to encourage a client to continue to communicate and/or to enrich what is being described.

• Given topic or life event

Therapeutic Use of Self

1. Modes

2. Attitudes

Therapeutic Use of Self: Modes

• Specific ways of relating to the client.

  • Different from listening and non-verbal cues

  • Warm, firm, or giving them space (depends on the client)

• Equally valued and therapeutic.

• Selection based on client’s needs and interpersonal characteristics.

• Mode shifts may be needed in response to interpersonal events.

Components of Modes

1. Instructing

2. Collaborating

3. Empathizing

4. Problem-Solving

5. Encouraging

Modes: Instructing

• Teaching and educating.

• Structuring activities clearly.

• Providing clear instructions and feedback.

• Setting limits when needed.

• Explain the plan, sequence, and events of therapy.

  • Why is it happening in that order

• We can praise while instructing

Modes: Collaborating

• Joint decision-making.

• Active and equal participation.

• Ensuring choice, freedom, and autonomy.

• Client involved in reasoning about therapy.

• Working as partners.

• The client leads but the therapist should also guide.

Modes: Empathizing

• Understanding client’s thoughts, feelings, and behaviors.

• Suspending judgement.

• Bearing witness to their experience.

• Validating their feelings.

• No need for advice or fixing.

• Not just having the right answer

Modes: Problem Solving

• acilitating pragmatic thinking.

  • Help the patient with what’s practical and doable

  • “Sir pano toh, pwede ba natin itong i-try?”

  • “Sir ano kaya mangyayari if mag-try ka ng journaling kesi sa mag-meditate tayo?”

• Outlining choices and options.

• Posing strategic questions.

• Trial and error and experimenting.

• Using reason and logic.

• Answers & solutions must be from the client.

Modes: Encouraging

• Instilling hope and courage.

• Celebrating thinking and behavior.

• Positive comments and praise.

• Conveying joyfulness, playfulness, and confidence.

• Inspiring willingness to explore and try.

• Not limited to positive comments of the output or outcome

Summary of Modes

Therapeutic Use of Self: Attitudes

1. Active Friendliness

2. Passive Friendliness

3. Kind Firmness

4. Matter of Fact

5. No Demand

Attitudes: Active Friendliness

Mode: Collaborating (mostly)

• Good for Initiating

Suitable For:

• Depressed, withdrawn, apathetic, isolated from others, shy, aloof.

• Stays in one state/room/setting all day, doesn’t talk, no internet

Manner of Delivery:

• Warm, cheerful, initiative-taking.

• The therapist assumes the initiative in making friendly overtures.

Strategies:

• Approach first

• Greet warmly

• Invite to activities

• Praise small efforts

• Sit with them even if quiet

• Use calm but cheerful tone

• Smile (can be neutral)

• Open posture

Attitudes: Passive Friendliness

You wait for them to take initiative

Suitable For:

• Paranoid, suspicious, distrustful, manic

• Thinks people are plotting again them, refuses food/interaction

Manner of Delivery:

• Calm, patient, non-threatening

• The therapist waits for the client to take initiative

Strategies:

• Stay 4 feet away

• Don’t touch

• Don’t approach suddenly

• Say “I’m here if you need me”

• Wait for them to start; Move slowly

• Don’t stare

• Be consistent

Attitudes: Kind Firmness

• Kind, present, and caring

• Firmness comes in the structure & expectations

• Validate their struggles

• Compassion but with accountability

• We OTs try to push the client to try even the client does not want to → set achievable  expectations

• Not as soft as active friendliness & not as hands-off as passive friendliness

Suitable For:

• Depressed, suicidal, uncooperative, sad, hopeless

• Patient says “I’m worthless,” refuses to get out of bed

Manner of Delivery:

• Gentle but firm, reassuring

Strategies

• Assign simple repetitive tasks

• Say “Let’s try this together”

• Don’t sympathize excessively

Attitudes: Matter of Fact

• Neutral and unemotional

• State the rule and stick to it (cx = manipulative)

• Don’t validate feelings the way you do in kind firmness

• Don’t get drawn into arguments or emotional reactions

Suitable For:

• Manipulative, demanding, impatient, character disorders, substance abuse

• Patient constantly asks for special favors, threatens to complain

Strategies:

• Keep voice neutral

• Say “The rule is..”

• Don’t argue

• Don’t show emotion

• Stick to rules

• Be consistent

• Explain routines clearly

• Follow through every time

Attitudes: No Demand

Suitable For:

• Assaultive, aggressive, furious, combative, violent

• Patient shouting, throwing objects, pacing aggressively.

Manner of Delivery:

• Calm, non-confrontational, team-based

Strategies:

• Don’t confront; don’t demand

• Remove others

• Call team

• Surround with group

• Say “where here to help you”

• Avoid direct eye contact

• Give space

• Return later when calm