Portal de Periódicos da CAPES

Occupational Therapists' Reflections on Meaningful Therapeutic Relationships and Their Effect on the Practitioner: A Pilot Study

2018; Volume: 1; Issue: 3 Linguagem: Inglês

10.3928/24761222-20180417-01

2476-1230

Tamera Keiter Humbert, Rebecca L. Anderson, Kendra N. Beittel, Emilia P. Costa, Abigail Mitchell, Emily Schilthuis, S. Williams,

Family and Disability Support Research

Original Research freeOccupational Therapists' Reflections on Meaningful Therapeutic Relationships and Their Effect on the Practitioner: A Pilot Study Tamera Keiter Humbert, DEd, OTR/L, , , DEd, OTR/L Rebecca L. Anderson, MS, OTR/L, , , MS, OTR/L Kendra N. Beittel, MS, OTR/L, , , MS, OTR/L Emilia P. Costa, MS, OTR/L, , , MS, OTR/L Abigail M. Mitchell, MS, OTR/L, , , MS, OTR/L Emily Schilthuis, MS, OTR/L, , and , MS, OTR/L Sarah E. Williams, MS, OTR/L, , MS, OTR/L Tamera Keiter Humbert, DEd, OTR/L , Rebecca L. Anderson, MS, OTR/L , Kendra N. Beittel, MS, OTR/L , Emilia P. Costa, MS, OTR/L , Abigail M. Mitchell, MS, OTR/L , Emily Schilthuis, MS, OTR/L , and Sarah E. Williams, MS, OTR/L Annals of International Occupational Therapy, 2018;1(3):116–126Published Online:April 17, 2018https://doi.org/10.3928/24761222-20180417-01Cited by:1PDFAbstract ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinkedInRedditEmail SectionsMoreAbstractObjective:The literature on therapeutic relationships in occupational therapy focuses primarily on the development of skills, attitudes, and approaches that practitioners should incorporate into the therapy process. Although evidence suggests that these relationships affect therapeutic outcomes, there is limited information on how they affect and influence the occupational therapy practitioner. This phenomenological study was conducted to elucidate how occupational therapists perceive meaningful therapeutic relationships.Methods:The resulting themes include entering into the client's world, forming a connection, maintaining equilibrium, and finding meaning.Results:These preliminary themes were supported by narratives and interviews obtained from six female occupational therapists who worked in pediatric and/or physical rehabilitation settings. Limitations of the study include the use of convenience sampling and the use of multiple novice researchers to complete data collection.Conclusion:The results of this pilot study provide evidence as to how meaningful therapeutic relationships may affect practitioners' personal and professional lives. Future research is needed to expand the study to include a variety of practice settings and different social, political, cultural, and temporal contexts. [Annals of International Occupational Therapy. 2018; 1(3):116–126.]IntroductionThe importance of therapeutic relationships has been documented for decades, and attention generally focuses on what the practitioner brings to the relationship (Frank, 1958; Peloquin, 2003; Schwartzberg, 1988; Taylor & Van Puymbroeck, 2013; Walker, 1971).The underlying belief espoused in the profession is that client-practitioner relationships offer a mechanism for recognizing, facilitating, and maximizing the therapeutic process (Doig, Fleming, & Kuipers, 2008; Weinstein, 2013). However, the literature has not addressed how these relationships may reciprocally affect the practitioner. The goal of this phenomenological study was to elucidate how occupational therapy practitioners perceive meaningful therapeutic relationships. For this study, we defined meaningful therapeutic relationships as self-described experiences that the practitioner perceives as personally significant.Literature ReviewOverview of Therapeutic RelationshipsTherapeutic relationships between practitioners and clients are considered central to occupational therapy practice (American Occupational Therapy Association, 2014; Taylor & Van Puymbroeck, 2013) and instrumental in achieving functional outcomes (Hall, Ferreira, Maher, Latimer, & Ferreira, 2010). Various constructs of the therapeutic relationship posit the practitioner and client engaging in diverse types of interactions influenced by professional knowledge and expertise (Maitra & Erway, 2006), perceived powers of authority (Crepeau & Garren, 2011; Haertl, Behrens, Houtujec, Rue, & Ten Haken, 2009), the personal lived experiences of clients and the value of incorporating them into the therapy process (Cleary, Hunt, Horsfall, & Deacon, 2012; Duff & Bedi, 2010), cultural sensitivity and responsiveness (King, Desmarais, Lindsay, Piérart, & Tétreault, 2015), and imagined professional roles (D'Cruz, Howie, & Lentin, 2016). External contexts that affect therapeutic relationships include restrictions on reimbursement and time devoted to intervention (American Occupational Therapy Association, 2014; Doig et al., 2008), types of practice settings (Palmadottir, 2006), and frames of reference used to support intervention and therapeutic approaches (Crepeau & Garren, 2011; Palmadottir, 2006).The term "therapeutic use of self," primarily used in the occupational therapy literature to describe an aspect of therapeutic relationships, highlights the role of the practitioner within the therapy process (Holmqvist, Holmefur, & Ivarsson, 2013; Taylor, 2008). The literature on therapeutic relationships and the therapeutic use of self is primarily conceptual and entails the practitioner developing skills and attitudes to form a working therapeutic alliance (Taylor, 2008). Preliminary empirical evidence suggests that there is variance in practitioners' understanding and appreciation of these multidimensional relationships as well as in their level of comfort with engaging in relationships effectively (Taylor, Lee, Kielhofner, & Ketkar, 2009).Perspectives of Occupational Therapy Practitioners on Therapeutic RelationshipsThe complexity of therapeutic relationships has been articulated in the occupational therapy literature. Practitioners perceive certain qualities as significant to the development of a positive therapeutic relationship, including empathy (American Occupational Therapy Association, 2014), compassion and transparency (Pooremamali, Eklund, Östman, & Persson, 2012), authentic respect (Darragh, Sample, & Krieger, 2001; Pooremamali et al., 2012), reciprocity (Crepeau & Garren, 2011; Morrison & Smith, 2013), humor (Crepeau & Garren, 2011; Holmqvist et al., 2013), trust (Palmadottir, 2006), and openness to communication (Holmqvist et al., 2013). Beyond practitioners' sense of the personal qualities that influence therapeutic relationships, client-practitioner collaboration is desirable in such relationships, and the literature emphasizes a particular disposition of "mutual and collaborative exchange between equals" (Tickle-Degnen, 2008, p. 404). This idea of mutuality is further supported in the third edition of the Occupational Therapy Practice Framework (American Occupational Therapy Association, 2014, p. S12): Clients bring to the occupational therapy process their life experiences and their hopes and dreams for the future. They identify and share their needs and priorities. Occupational therapy practitioners bring their knowledge about how engagement in occupation affects health, well-being, and participation; they use this information, in addition to theoretical perspectives and clinical reasoning, to critically observe, analyze, describe, and interpret human performance.Mutual and collaborative approaches incorporate therapeutic principles, such as using intentional listening (Romanoff & Thompson, 2006) and active listening (Crepeau & Garren, 2011), co-constructing narratives (American Occupational Therapy Association, 2014; Mattingly, 2000; Wicks & Whiteford, 2003), finding common ground (Rosa & Hasselkus, 2005), and integrating spirituality into practice (Egan & Swedersky, 2003; Gockel, 2011; Luboshitzky, 2008).Yerxa (2005) extended another concept beyond mutual exchange in her description of authentic occupational therapy in which the practitioner experiences genuine emotions during reciprocal interactions with the client. For practitioners to enter into such reciprocal interactions, they must be receptive to clients' thoughts and emotions (Yerxa, 2005). Yerxa noted that "the authentic occupational therapist is involved in the process of caring and to care means to be affected just as surely as it means to affect" (Yerxa, 2005, p. 138).SummaryWithin the occupational therapy literature, it is assumed that therapeutic relationships are important and central to the therapeutic process, that they can affect the outcome of therapy, and that they are influenced by practitioners' personal qualities and dispositions as well as by the approaches used. Although therapeutic relationships are influenced by practitioners' internal contexts, therapeutic environments, and external contexts, there is also an ideal that therapeutic approaches should be mutual and collaborative (American Occupational Therapy Association, 2014). Yerxa (2005) pointed to another level of understanding that these relationships also may have a significant effect on the practitioner. What is missing in the empirical literature is recognition of any reciprocal benefit of therapeutic relationships that practitioners might perceive as significant. In particular, we do not understand how practitioners experience therapeutic relationships and how these relationships influence the practitioner's professional role. In an effort to expand the understanding of therapeutic relationships beyond what the practitioner brings to them to include what practitioners experience through meaningful therapeutic relationships, this pilot study was conducted to elucidate occupational therapists' perspectives.MethodsStudy DesignThis study used a phenomenological design (Creswell, 2013; Wilding & Whiteford, 2005) to explore practitioners' meaningful therapeutic experiences with clients. Six female participants who were occupational therapists with 5 to 30 years of clinical practice in pediatric and/or physical rehabilitation settings initially shared personal narratives about such relationships to inform the research process (Table 1). The researchers performed extensive coding and constant comparative analysis of transcripts to identify initial themes and develop probing questions for a second interview with the participants (Saldana, 2009). Additionally, multiple points of member checking and a follow-up e-mail at the end of the study were included to clarify the identified themes with the participants. The summative flow chart describes the research process (Figure).Table 1 Description of ParticipantsParticipantYears of experienceAreas of experience17Outpatient rehabilitation, acute rehabilitation, intensive care25Inpatient rehabilitation, acute care, outpatient320Outpatient pediatrics, school system430Inpatient rehabilitation, pediatrics59Inpatient rehabilitation630Outpatient pediatric rehabilitation, early intervention, school system, community-based pediatricsFigure: Methods flowchart. COTA = certified occupational therapy assistant; OTR = occupational therapist registered; PI = principal investigator.Ethical ConsiderationsBefore the start of the study, approval was obtained from the institutional review board at Elizabethtown College. Before the interviews were conducted, informed consent was obtained from each participant. No conflict of interest was declared. Confidentiality was maintained, and no identifying information, such as state of residence and employer, was revealed to protect participants' identities.ResearchersAt the time of the study, the primary investigator was a licensed occupational therapist with 30 years of experience as well as 7 years of experience as a certified occupational therapy assistant. The primary investigator has completed multiple phenomenological studies over the past decade. Along with the primary investigator, the researchers included six occupational therapy graduate student researchers who had successfully completed applicable research coursework and one level II fieldwork experience in a physical rehabilitation or mental health practice setting. Before the start of the project, all of the researchers shared personal narratives about their own meaningful therapeutic relationships. The intent was to begin the process of listening to others' narratives (Brinkmann & Kvale, 2015), explore personal responses to the topic (Creswell, 2013), and introduce empathy into the listening process (Luft & Overgaard, 2012). The researchers wondered whether other practitioners had experienced and could articulate meaningful therapeutic relationships and describe how these experiences affected them as well as whether this phenomenon could be better elucidated.ParticipantsPotential study participants were identified through convenience and snowball sampling by the primary investigator. The participants either were known to the primary investigator and had previously shared narratives about client-practitioner relationships that held great personal meaning or were referred to the primary investigator because of expressed interest in the study. All study participants were occupational therapy practitioners with at least 5 years of experience who could identify and articulate a meaningful client-practitioner relationship within any practice setting. Six female licensed occupational therapists were recruited to participate in this study. Their clinical experience ranged from 5 to 30 years, and their respective practice areas were variable but primarily included pediatric and/or physical rehabilitation (Table 1).Data CollectionData were collected through two in-depth telephone interviews, conducted either through Skype or in person, at the convenience of the researchers and participants, as well as through e-mail communication. Each occupational therapy graduate student researcher was randomly assigned to a participant, and all communication, including the completion of both interviews, was conducted within these assigned dyads. The approach was used to promote trust between researchers and participants over time and with multiple in-depth interviews and interactions (Brinkmann & Kvale, 2015), to enable greater intersubjectivity and presence during the interviews (Luft & Overgaard, 2012), and to provide multiple opportunities for self-reflection and collaboration with participants within a focused designated time frame (Anderson & Braud, 2011; Creswell, 2013). Before they conducted the interviews, the graduate student researchers completed various listening activities and mock interviews with the primary investigator and within their own self-identified community of learning (Brinkmann & Kvale, 2015).The first interview was semistructured and was guided by one leading prompt: Tell me a story or describe a time in which you had a meaningful or powerful connection with a client. The second interview was more structured, and the goal was to clarify and elaborate on identified preliminary themes from the initial analysis of the narratives. The researchers asked probing questions to clarify and facilitate sharing of information. Questions for the second interview included: 1.Tell me how you understand emotional attachment and detachment with clients. When do you do each, why, and how?2.With many of the participants, we could see that they had certain things in common with clients (e.g., culture, age, gender). Can you think of another powerful or meaningful story in which you did not have things in common with a client? Were you still able to connect? Is having similarities something you consider helpful in forming a connection?3.We noticed many of the stories that participants shared involved forming a relationship over a long period of time. Have you had any meaningful experiences that developed over a shorter period of time with a client?4.We want to understand the transformation of the therapist. We would like you to think about four other clients or families that come to mind (can be past or present). Consider what you learned through your experiences with those clients or families.All interviews were audio-recorded and transcribed verbatim. After completion of the second cycle of coding, the researchers posed another prompt to the participants via e-mail to encourage them to further elaborate on their insights relative to the themes of the study.Data AnalysisAfter the initial interviews were completed and transcribed, the researchers participated in the first cycle of coding, which included structured and descriptive coding of the topic and content, affective coding of emotions and values, and exploratory, holistic thematic coding (Saldana, 2009). After the second interviews, the second cycle of coding was completed and consisted of pattern coding and focused coding to highlight preliminary but salient ideas (Saldana, 2009). For both cycles of coding, constant comparative analysis was used to identify common themes that emerged within and between all transcripts.Triangulation and CredibilityThe researchers used a variety of approaches to promote credibility in data collection and analysis (Carter, Lubinsky, & Domholdt, 2011). All interviews were audio-recorded and transcribed verbatim to ensure accurate records of participants' responses. All of the transcripts were first coded individually by each of the researchers. The initial themes were then shared and discussed collaboratively; only the themes evident to the entire research team were used for continued analysis. The researchers also used journaling as a tool to reflect on their insights and actively engage in the research (Creswell, 2013). Member checking also was used to confirm the identified themes before they were finalized. Only themes that were agreed on by all researchers were reported in the final results (Creswell, 2013).ResultsThe findings showed four overarching themes that describe the elements of a meaningful therapeutic relationship as perceived by the occupational therapists. The themes include entering into the client's world, forming a connection, maintaining equilibrium, and finding meaning. These themes were supported by participants' narratives of meaningful therapeutic relationships and by the follow-up interviews.Entering Into the Client's WorldEntering into the client's world occurs when the occupational therapist honors the client and the client's experiences. It is a mind-set or attitude that the therapist brings to the therapy process. This was evident when therapists acknowledged clients' experiences, changed approaches to meet clients' needs, or were just present in the moment with clients (Table 2). When participants acknowledged clients' experiences, they often expressed empathy and validated clients' realities. Participant 2 noted, "If you don't meet their emotional needs and acknowledge them and respond to them, I don't think we would be able to get anywhere physically. You need to be emotionally there." Often participants changed their approach as they came to understand each client's unique personality and needs. Participant 2 also shared, "You almost have to be an actress in the sense that you don't change who you are, but you change who you are based on what people need." Being present in the moment also allowed participants to enter into the client's world by fully committing themselves to the here and now as they engaged clients in the therapy process.Table 2 Themes and Supporting EvidenceThemeSupporting evidenceEntering into the client's worldThe wife was questioning the long-term plan, thinking that eventually [her husband] might have to be in a nursing home. She was crying. . . . I touched her hand and told her that she isn't giving up on him. She's looking out for him. Even though she knows that her husband might not like the next step, it may be best for both of them. These thoughts and feelings are out of love and compassion, and it is not giving up; it is getting help and moving along. (Participant 5)We have to be able to adapt, to be flexible ourselves so that we can be with the client . . . so we can meet the needs right then and there. (Participant 6)One time, we [the physical therapist and I] were helping him sit at the edge of the bed, and he started to get anxious. I held his hands and tried to calm him down. I truly believe that clients can sense when you are fully present in that moment with them. . . . You connect to them better. (Participant 3)Forming a connectionWhen you meet someone and you just . . . right away you have something in common or you have similar personalities or interests, or maybe they're charismatic and you respond well to that, but I think there's a natural thing that you like about that person. They respond to you, and then a bond kind of forms . . . like a friendship bond. (Participant 2)And you're also doing pretty intimate things with people, so helping someone shower for the first time in a month. . . . They'll remember you for that, even if you only see them one day. So you know that for one session, one day, I was able to create a relationship with her. (Participant 1)Yesterday she was in the kitchen. . . . She was laughing and smiling. . . . Her two daughters came in for family training, and it was like a whole new world. She was a whole new person. She was just so happy to be able to stand and cook and be with her kids. It was very powerful just to see those things. (Participant 5)Maintaining equilibriumYou can get burned out so quickly. . . . It's a very tough, emotional job. I mean sometimes they're [clients] scared. They're going through so much too, and naturally, as a human, you feel all those emotions too. And you know, if you care about somebody, care about getting them better and stronger, you kind of get wrapped up in their story and you want to help them. So many people have shared so many things. . . . I have to make sure it doesn't weigh me down. (Participant 5)I had a patient. She happened to be Ukrainian, and I'm Ukrainian. And she only spoke Ukrainian. . . . I'd walk in and she'd explain her pain to me in Ukrainian, and it would almost be like a knife . . . the way she spoke in Ukrainian. There was something about it that just touched me. No one else understood it because they didn't know what she was saying, but the words she would use to describe her pain . . . it was like getting daggers stuck inside of me. (Participant 5)Finding meaningThat changed how I treat people too. It made me try to do more therapeutic passes. It made me try to emphasize and explain the rationale of why we are doing activities to make sure that they are able to be independent in the community, educating families about the importance of doing things. . . . I can go home and have my own life, but this is their life. . . . It was just very eye-opening for me. (Participant 1)I just pulled the parents aside, and I said, "I just want you to know how powerful your son is and [the experience] changed my life." And they said, "What are you talking about?" And the mother started crying, and she said, "That is the first time I've ever felt like he has been accepted." (Participant 6)Forming a ConnectionConnections with clients may occur instantly because of similarities between the practitioner and the client or may develop over time based on their shared investment in the therapeutic process. Participants also discussed "tipping points," times when a breakthrough occurred in the relationship that strengthened the connection between client and therapist (Table 2).The narratives and interviews showed a continuum of ways in which therapists formed connections with clients. This continuum ranged from connections that occurred naturally to those that formed through a directed effort by the therapist. Participants had difficulty describing the natural connections that occurred, but some participants compared them with an effortless beginning or an initial friendship. Participant 5 described this process, saying: It's almost like when you meet somebody, like a new friend, you're interested in their life. You get excited 'cause you like the person. You're so moved by the person or inspired by the person. You want to know everything about them.Each participant shared at least one instance in which a therapeutic relationship formed naturally through similarities (e.g., hobbies, interests, life circumstances) that allowed the participants to find common ground. In contrast, some connections took added time and effort to develop. Some participants suggested that clients may be hesitant to trust practitioners, but noted that the establishment of trust was highly important. Participant 6 commented, "I have to figure out how I can connect with this kid so we can have a good working relationship. So that makes me think about finding out what their interests are."According to the participants, the duration of the therapeutic relationship had the potential to strengthen the connection between practitioners and clients and allowed practitioners to begin to understand "how and why they got to where they are and what brought them here" (Participant 4). The time spent together allowed participants the opportunity to deepen their knowledge of clients. Although participants noted that spending more time with a client was helpful in forming a connection, they also shared stories about meaningful connections that formed quickly, within days or even hours, when the therapeutic activities were intense, such as during personal activities of daily living and within the context of end-of-life care.The participants acknowledged the value of the therapeutic process when both the therapist and the client recognized the potential for growth and committed themselves to the therapeutic process. Shared investment, mutual respect, and acceptance of the therapeutic process facilitated the connection between therapist and client. However, tipping points also occurred when the shared investment was not realized initially. Tipping points are conceptualized as a moment within the therapeutic relationship in which a breakthrough occurs in the relationship and within the therapeutic process. This breakthrough may entail a client reaching a therapeutic goal or enhancing occupational performance that was not realized previously or a client disclosing personal information. Tipping points created a connection between the therapist and the client on a different level than connections based on personal similarities or the length of the relationship. These moments allowed the therapist to learn more about the client and, in a sense, find the key that unlocked the client's potential for occupational performance. A tipping point could occur at any time during the therapeutic process. According to Participant 5, "It's almost like you have a sense they're ready; they want to talk to you about something or they feel a certain way."In addition, practitioners could reach a tipping point at any point within the therapeutic process. Participants spoke about moments of awareness or moments that occurred after periods of reflection that brought greater insight about clients and their challenges. Participant 2 stated: What I learned from that relationship was that even though I'm sort of, I guess, the 'expert,' the occupational therapist, [and I know] the function of her arm and [activities of daily living], I'm not the expert on her life.Maintaining Equilibrium: Attachment Versus Stepping BackAccording to participants, both the client and the occupational therapist bring vulnerabilities, emotional needs, and shared humanity to the therapeutic relationship. Participants noted that recognition of the therapists' and clients' emotional needs helped to form a strong therapeutic relationship. Sometimes the therapeutic relationship felt effortless and mutual; however, at other times, practitioners were encouraged or felt obligated to put clients' needs before their own. The recognition of emotional needs led to acknowledgment of the humanity of both client and practitioner and recognition of the challenge, at times, of finding the balance between the importance of forming a greater connection with the client and the need to establish additional professional boundaries. Tension occurred when practitioners were challenged to maintain a balance between professional roles and their own and their clients' personal needs. Participant 5 explained: You can tell you're becoming a little bit more emotionally attached when you feel your emotions change with the client. You want to keep reaching out to them to help them in some way. Like they're almost . . . I wouldn't want to say 'friends'; that's overstepping a boundary. I think sometimes you have to realize that it can cross a boundary when they, maybe, are depending too much on you.In particular, participants articulated a struggle in finding the balance in professional roles when explicit boundaries were not established by work policies. In such circumstances, therapists needed to determine their level of comfort in this equilibrium. For example, Participant 1 explained, "I created boundaries by not accepting patients as friends on social media." However, Participant 5 stated, "[When] they're not clients anymore, then we feel more comfortable accepting their friendship on Facebook."The participants reported what they learned about their own emotional needs as well as the importance of responding to clients' needs (Table 2). The participants acknowledged that therapists' knowledge of their own personality and how it affects their treatment of clients may be significant for achieving balance in the client-practitioner relationship. As Participant 2 shared, "I create more barriers now because I'm a sensitive person, and like some people do, I get caught up in emotions, whereas other people wouldn't let themselves be affected." Sometimes this awareness of their own personal characteristics and emotional health led to a recognition of the inherent limitations within the role of therapist. Participant 3 reported, "I would have these very strong feelings, and I would have to remind myself on a regular basis that he isn't my child. This [situation] is not mine to change."Finding MeaningBased on the narr