Therapeutic Use of Self: What Does That Even Mean for OTs?
For graduate students who are just barely diving into their OT school studies, concrete and unchanging topics such as medical terminology are much more understandable than intangible concepts.
At least, in some programs, we can physically see and touch the terms through cadaver labs and dissection. It is why the medical model is so nice because we can observe diagnoses and symptoms in our patients/clients.
The one concept we have a harder time grasping until we’ve developed it in practice is “therapeutic use of self.”
Instead of using our perspective to view hard facts about the client, the environment, or the occupation (and then documenting it), we now have to look inward and use ourselves to produce meaningful purpose and communication.
So What Exactly IS Therapeutic Use of Self?
As a profession, could we be any more vague?
What does it exactly mean to incorporate a “therapeutic use of self” into practice?
One of the great theorists in Occupational Therapy, Gary Kielhofner, along with several of his colleagues, explained the concept beautifully (Kielhofner, 2004; Schwartz, 2003 as cited by Taylor et al. 2009):
“Early occupational therapists viewed the therapeutic use of self as a means for encouraging clients to engage in occupation.”
The most widely cited contemporary definition of therapeutic use of self describes it as a therapist’s “planned use of his or her personality, insights, perceptions, and judgments as part of the therapeutic process” (Punwar & Peloquin, 2000, p. 285 as cited by Taylor et al. 2009).
Of course since 2009, “therapeutic use of self” has evolved in the clinical setting and dedicated researchers acknowledge that in the growing literature.
Therapeutic use of self is what creates a meaningful relationship between the therapist and the patient in order to produce meaningful participation and progress in occupations that matter to the patient.
Instead of concentrating on evidence-based research, we’re going to talk about utilizing therapeutic use of self in practice in an actual therapist-patient interaction.
A Case Study
Cynthia is a 48-year-old female patient residing at a skilled nursing facility. She was admitted following a 4-day hospital stay after sustaining a right lower extremity femur fracture as a result of a ground level fall in her home.
Lauren is the occupational therapist at the skilled nursing facility and has just received the order to evaluate Cynthia.
According to the medical chart, Cynthia has orders for non-weight-bearing precautions on her right leg for the next 4 weeks. Because of her ORIF (open reduction internal fixation), she is sponge-bath only for at least 2 weeks until doctor approval for showers.
Cynthia has a history of bipolar disorder, uncontrolled Type II diabetes, multiple falls, and substance abuse. Nursing staff has already informed therapy about Cynthia’s non-compliance with her current precautions and attempts to avoid treatment of all varieties.
Think about what it takes to establish a relationship with a new friend and what the motives would be for solidifying that connection. You would first get to know that individual, asking questions regarding their hobbies, their job, their friends and family, etc.
In exchange, you would offer information about yourself, find the similarities, and harbor trust. Of course, developing a relationship with a patient has its own framework and limitations in order to maintain professionalism.
Collecting Information Through Communication and Observation
During the evaluation, the therapist needs to collect information or “insight” about Cynthia verbally and through observation:
Is Cynthia alert and aware?
This should be considered due to her history of mental illness. Regular medications will also affect her awareness and her willingness to participate in therapy.
Was she completely independent in her prior level of function?
The therapist should have some suspicion that independence was limited in some capacity due to her history of falls.
What are Cynthia’s routines and hobbies?
These are tasks outside of her required daily tasks such as showering, dressing, and toileting. Reviewing required tasks during intervention time repetitively will get old and Cynthia could lose interest in attending therapy sessions.
By using hobbies that are relevant to treatment and that Cynthia enjoys, the therapist can strategically hook her into therapy in order to increase functional progress.
What are Cynthia’s priorities and functional goals for treatment?
The therapist needs to let Cynthia have the say in her own treatment, or else intervention is meaningless and much less enticing for her. The therapist needs to take a little and then give a little like you would in any other relationship.
If the therapist dictates the patient’s goals and how they are to be addressed without the patient’s input, then it just cultivates a one-sided relationship that won’t produce results.
Does Cynthia exhibit any type of manipulative behavior that could negatively impact her participation in therapy?
This can happen for any patient, but it is especially important to identify this barrier with patients with mental illnesses. In order to prevent a straight-up refusal, the therapist needs to be prepared with counter-offers and education in order to encourage participation.
Does Cynthia have any close family members or friends she wishes to be included in her therapy?
Progress can occur when a patient’s family attends sessions to show their support.
Additionally, therapists can get a feel for what communication styles are effective for Cynthia based on how close family and friends communicate with her. Communication styles include tone, volume, word length per sentence or command, etc. They would know what makes the patient happy, angry, nervous, or sad.
How does Cynthia respond to the therapist’s communication style?
Does Cynthia reciprocate conversation with the therapist’s style or does she shut down? Does her anxiety increase or does she seem at ease? Does she respond more positively to blatant commands or to mild suggestions? While the therapist is communicating, they need to have a keen eye for subtle changes in the patient’s behavior as they speak.
What information about the therapist could be offered to Cynthia?
In order for Cynthia to portray trust, the therapist needs to place a few cards on the table and provide some personal information that the patient could relate to. Providing simple favorites and life experiences can make a positive difference.
With the above information, the therapist could make some valid judgments and perceptions about the patient’s participation in meaningful tasks, know when to change or maintain their therapeutic use of self, and promote progress in order for her discharge back home.
I hope this case study helped shed some light on the meaning and usage of therapeutic use of self in practice. I hope it also gave you some ideas of how to apply it in your practice.
Do you have any of your own examples of how incorporating therapeutic use of self helped in your OT practice? Please feel free to share in the comments below.
Additional References and Resources
Taylor, R.R., Lee, S.W., Kielhofner, G., & Ketkar, M. (2009). Therapeutic Use of Self: A Nationwide Survey of Practitioners’ Attitudes and Experiences. American Journal of Occupational Therapy, March/April 63(2).