OTA 102 – Chapter 19: Therapeutic Relationships
Psychology of Rehabilitation
OT clients typically experience some degree of loss (roles, abilities, social identity, independence).
Elisabeth Kübler-Ross identified five universal stages of loss:
Denial
Anger
Bargaining
Depression
Acceptance
Key implications for OT practice
Clients may progress non-linearly, skip stages, or cycle back.
Practitioners should recognize a client’s current stage to adjust communication style, goals, and emotional support.
Purpose-built activities, graded challenges, and empathetic dialogue help clients work through each stage.
Ethical duty: respect autonomy while encouraging realistic hope.
Therapeutic Relationship
Definition: A goal-directed, time-limited interaction in which the client gains the primary benefit.
Quality of the relationship can augment or undermine therapeutic outcomes.
Central construct: Therapeutic Use of Self
Conscious, planned interaction using personality, perceptions, judgments.
Requires continual self-reflection, adaptation, and boundary management.
Self-Awareness
Three inter-related images of self
Ideal Self: who I aspire to be.
Perceived Self: how I believe others see me in the moment.
Real Self: the authentic blend of strengths, limitations, thoughts, and feelings.
Strategies to develop self-awareness
Journaling & reflective writing after sessions.
Participation in group labs to reveal personal strengths/weaknesses.
Request structured feedback (tone, body language, clarity).
Video-record an intervention; perform a self-critique.
Provide constructive feedback to peers (mirrors self-insight).
Ethical reflection exercises (scope, autonomy, cultural humility).
Skills for Effective Therapeutic Relationships
Skills are learnable & refinable through deliberate practice.
Cultural adaptability
Adjust communication, activity selection, and nonverbal cues to align with diverse cultural norms.
Emphasize occupational justice and inclusivity.
Metacompetencies
Emotional intelligence, boundary setting, timing, graded self-disclosure.
Developing Trust
Foundational to risk-taking and occupational engagement.
Evidence-based techniques (cf. text pg. 260)
Consistency: start & end sessions on time, follow through on promises.
Honesty & transparency: realistic goal setting, plain-language explanations.
Active presence: undivided attention, eye contact, therapeutic touch when appropriate.
Confidentiality: clarify privacy policies; never discuss other clients.
Client control: offer choices, respect refusals.
Self-disclosure guidelines
Purpose: benefit the client, never to vent or seek sympathy.
Avoid disclosing in the midst of a client crisis.
Do not give personal address or personal phone number; maintain professional boundaries.
Filter content: only share information that directly promotes therapeutic goals (e.g., a brief story illustrating coping skills).
Developing Empathy
Empathy = ability to enter another’s perceptual world and convey understanding.
Methods to cultivate empathy
Read autobiographical accounts of illness/disability.
Engage in cross-cultural experiences (community events, service learning).
Conduct narrative interviews; ask open-ended, life-story questions.
Participate in simulation labs (e.g., goggles for low vision, hemiparesis splinting, wheelchair navigation) to feel embodied challenges.
Clinical payoff
Enhances rapport, motivation, and adherence.
Decreases implicit bias; supports client-centered goal selection.
Communication
Core conduit for information gathering, intervention planning, and outcome evaluation.
Verbal Communication (pg 261)
Attributes: tone, pacing, volume, clarity.
Use client-friendly vocabulary; avoid jargon.
Ask open-ended questions first, then targeted probes.
Match literacy level; employ teach-back to confirm understanding.
Nonverbal Communication (pg 262)
Components: facial expression, eye contact, posture, proxemics, touch.
Cultural variations (e.g., eye contact norms, personal space) must be respected.
Congruence between verbal & nonverbal messages signals authenticity.
Active Listening
Purpose: verify comprehension and validate feelings.
Three primary techniques
Restatement: Repeat the content using the same or similar words.
Reflection: Paraphrase with an emphasis on emotional subtext.
Clarification: Summarize, then ask for confirmation or elaboration.
Outcome: prevents misinterpretation, deepens therapeutic alliance.
Intentional Relationship Model (IRM)
(ref. Fig. 19.5 & 19.6, pp 263-264)
Conceptual model describing six interpersonal modes—adaptive, deliberate ways OT practitioners relate to clients. Each mode is neutral; effectiveness depends on timing and client preference.
Advocating
Focus: securing resources, removing environmental barriers, upholding occupational justice.
Example: helping Gordon obtain adaptive equipment funding.
Collaborating
Emphasizes shared decision-making; values client autonomy.
Example: co-creating the weekly home program schedule.
Empathizing
Prioritizes listening, validation, and emotional attunement.
Example: acknowledging grief after sudden hemiparesis.
Encouraging
Uses positive reinforcement, playful energy, and motivational framing.
Example: celebrating incremental dressing milestones with verbal praise.
Instructing
Provides clear education, structured feedback, and safe limits.
Example: step-by-step demo of wheelchair transfers.
Problem-Solving
Analytical approach: reasoning through barriers, modifying tasks/environments.
Example: brainstorming kitchen adaptations with the client.
Ethical alignment: practitioners should flexibly shift modes as client needs evolve; rigid use may hinder rapport.
Case Connection – “Gordon” (pg 258)
Illustrates interplay of loss stages, self-awareness, and IRM modes.
Highlights need for early trust-building, graded self-disclosure, and culturally sensitive goal setting.
Integrative Themes & Real-World Relevance
Rehabilitation psychology underpins all OT interventions—ignoring emotional stages risks noncompliance.
Therapeutic relationship skills reduce length of stay and improve functional outcomes (evidence from client satisfaction studies).
Cultural humility is a practice standard, linked to AOTA’s Vision 2025 commitment to diversity and inclusion.
Ethical considerations: boundaries, informed consent, and respect for client dignity are non-negotiable.