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.
Overview of Therapeutic Relationships
Therapeutic 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 Relationships
The 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).
Within 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.
This 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).
Description of Participants
Methods flowchart. COTA = certified occupational therapy assistant; OTR = occupational therapist registered; PI = principal investigator.
Before 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.
At 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.
Potential 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 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:
Tell me how you understand emotional attachment and detachment with clients. When do you do each, why, and how?
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?
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?
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.
After 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 Credibility
The 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).
The 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 World
Entering 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.
Themes and Supporting Evidence
Forming a Connection
Connections 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 Back
According 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.”
Based on the narratives shared by the participants, occupational therapists may experience both professional and personal growth as well as transformation through meaningful client relationships. These changes helped to guide practitioners through current and future relationships with clients. The narratives suggested that occupational therapists may gain new insights that enable them to grow as professionals, and some participants shared how these relationships challenged previous biases they had toward individuals with specific diagnoses or personal characteristics (Table 2).
Alternatively, some practitioners mentioned personal growth, which is something that can be applied more broadly. Many participants spoke about learning from interactions with clients and their clients' stories. Participant 5 stated, “It's not only us teaching patients techniques. They're teaching us life skills.” Participant 3 noted, “[I] call them ‘life lessons’ that the kids have taught [me].” Often these experiences build on each other. According to Participant 5, the practitioner will “grow from that experience and move on to the next experience” and “learn from it and keep going.” Participant 1 noted, “It's like every patient I work with, I learn a little something.”
A possible outcome of meaningful relationships with clients is transformation, which can be understood as a moment or experience that leads to deep change. All participants noted how these relationships not only allowed them to grow personally and professionally but also subsequently changed their lives. For example, Participant 6 shared how clients she worked with left a lasting impression on her, noting, “There are certain [people] you will never forget, and you will always be attached to [them] because [the experience] really, really has changed you in a deep way.”
Some components of entering into the client's world that were described by the participants are noted elsewhere in the literature. Showing empathy (Peloquin, 2003), honoring clients' subjective experiences and life stories (Romanoff & Thompson, 2006), and being present for clients (Crepeau & Garren, 2011) can facilitate formation of the therapeutic relationship. Additionally, the results of this study point to a dynamic approach, a willingness of the therapist to actively change roles and approaches to better enter into the client's world. According to the participants' descriptions of these relationships, the intention behind therapists' flexibility in changing personal approaches was not to facilitate a particular therapeutic response but instead to understand clients more fully and develop connections with them.
The participants referred to the relationships they had formed with clients as developing along a continuum that ranged from natural to effortful. Although the literature describes intentional and sometimes effortful relationships with clients (Palmadottir, 2006; Romanoff & Thompson, 2006; Taylor, 2008), less information is available on those that form automatically. Palmadottir (2006) briefly described client-practitioner interactions that feel natural or occur easily. Although few studies have reported on this topic, all participants shared at least one experience in which a meaningful relationship with a client formed naturally as a result of having characteristics in common (e.g., age, nationality, interests). Although many participants mentioned commonalities with clients as helpful, they were still able to form powerful connections in the absence of those similarities and even in cases when there was tension in the relationship.
Participants understood shared investment as commitment to the therapeutic process by both the client and the practitioner as well as recognition of the potential for growth toward therapeutic goals. All of the participants shared experiences of disconnect with clients. The disconnect was sometimes followed by tipping points, when a new connection was made and a breakthrough occurred in the relationship or therapeutic process. Darragh et al. (2001) validated that practitioners can damage the therapeutic relationship if they disregard the client and are unwilling to listen. Although Darragh et al. (2001) alluded to the idea of tipping points, there is limited explanation of this phenomenon in the literature. According to participants' narratives and later interviews, clear demarcations can occur within the relationship when something shifts and the practitioner has an insight or an aha moment that moves the therapeutic relationship to another level.
The participants recognized that both clients and therapists bring vulnerabilities, emotional needs, and shared humanity to the therapeutic relationship. Many participants shared stories of personal tension that occurred as they were challenged, at times, to maintain balance between professional roles and their own and their clients' emotional needs. According to Taylor (2008), occupational therapy practitioners must recognize their own emotional responses to clients, cope with these responses, and act appropriately to maintain the therapeutic relationship. Our study highlights Taylor's (2008) findings as the participants acknowledged their internal responses to clients and expressed their attempts to cope with these responses through dialogue with other practitioners, self-talk and personal reflection, and engagement in stress-reducing activities outside the work environment. Although participants acted to preserve these relationships during challenging times, they also acted intentionally to maintain their own emotional well-being and further clients' successes. This study showed different means by which practitioners acted to meet clients' emotional needs and attend to their own emotional well-being. These included distancing themselves and reinforcing boundaries.
Finally, the participants expressed gratitude for the benefits that they received through these personally identified meaningful relationships. Participants described therapeutic relationships that led to personal and professional growth and even deep transformation. The participants described the benefits of these relationships, which included learning how to individualize treatment based on client factors, improving clinical decision-making skills, learning personal “life skills” through the experience, and being “forever changed.” Participants acknowledged that meaningful therapeutic relationships can provide practitioners with something more than witnessing client success and achieving therapeutic goals. These relationships also may enrich the therapist's personal and professional life journey.
Implications for Occupational Therapy Practice
The most recent version of the Occupational Therapy Practice Framework recognizes therapeutic use of self as part of the occupational therapy process (American Occupational Therapy Association, 2014). This is an expansion of the second edition of the Occupational Therapy Practice Framework, in which therapeutic use of self was represented simply as applicable to providing interventions (American Occupational Therapy Association, 2008). This change emphasizes that therapeutic use of self is integral to the entire therapeutic process and that it can be employed in all interactions with clients (American Occupational Therapy Association, 2014). In light of this increased focus, practitioners must understand the implementation of this practice more comprehensively. Regardless of the intervention context, practitioners are expected to form and maintain therapeutic relationships with clients. This pilot study adds to our current understanding that therapeutic relationships also may have significant benefit for occupational therapy practitioners.
Future Research Considerations
Although there is conceptual knowledge of the therapeutic use of self, literature on reciprocal therapeutic relationships is limited. Many aspects of this type of relationship are not fully understood. In our pilot study, many participants described meaningful relationships that occurred earlier in their careers. Even participants who had 20 or more years of experience explicitly noted powerful incidents that occurred when they were still novice practitioners and provided rich details about those interactions. The question, then, is whether practitioners tend to have more of these relationships earlier in their careers. Taylor et al. (2009) noted that younger practitioners were more likely than older practitioners to experience concern for clients. Is it possible that practitioners are more open to these experiences in the early stages of learning and thus find more meaning in them? More research is needed to better understand how such experiences affect practitioners' evolving professional lives.
This study brought to light practitioners' perspectives on the therapeutic relationship; however, more research is needed to understand how clients describe their experiences of meaningful relationships with occupational therapy practitioners. Do clients view these same relationships as powerful, or is this something experienced only by the practitioner? If clients do find these relationships powerful or meaningful, how do they describe these experiences?
Lastly, a goal of the study was to elucidate occupational therapists' meaningful therapeutic relationships within any practice context. We did not interview any practitioners working within a mental health practice setting, and we did not further clarify the implications of the social, political, cultural, and temporal contexts on meaningful therapeutic relationships. Additional study to include more varied participants and contexts is needed.
Participants were chosen through convenience sampling by the primary investigator, and bias may have been introduced through the use of this method. A phenomenological methodological approach urges a lack of structure to the design (Flood, 2010), and the use of a semistructured interview format as well as the use of multiple and novice researchers may have led to inconsistent approaches to interviews and data collection.