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Therapeutic Relationships: What you might not know

People who study therapeutic hypnosis, neuro-linguistic programming and other forms of brief therapy know the effectiveness of using rapport-building, pacing, utilization, re-framing, pre-framing, pattern-interrupting, and other hypnotic language patterns. These tools are used by the best coaches, teachers, and therapists to maximize results in their therapeutic relationships. They are significant elements in the change-work repertoire of necessary skills for anyone involved in therapeutic relationships. A broad selection of behavioral-response options would be useful for any circumstance where a requisite variety of flexible behaviors would be beneficial. Imagine how often that is!

“The Law of Requisite variety states that the person with the most flexibility of behavior will rule the system” -NLP Presupposition (also, the 1st Law of Cybernetics)

Anytime you experience unnecessary resistance, lack of cooperation or a need to step out of the box, flexibility in your thinking will open new options for you. Do you have the requisite variety of flexible behaviors to deal with whatever your clients throw at you? If not, consider exploring an out of the box approach when modifying your responses. The best solution is not always obvious or as straightforward as many assume. Mastering this takes practice and some training in strategic communication is definitely helpful. What a select few know about these approaches is that they can potentially be a vital part of something referred to in occupational therapy as the “Therapeutic Use of Self.”

As a guest lecturer for the Grand Rounds Lectures at Stanbridge College in Irvine, CA, I spoke to students about what comprises this therapeutic approach and how to apply it in their future work. As occupational therapists, these students will have ample opportunities to employ these skills and be resources for positive growth and healing for their patients. It is important that these new practitioners accept their role as leaders, for the guidance they provide will come not only from the methodologies of occupational therapy, but also from the qualities they emit from their therapeutic personas.

This aspect of therapeutic work is one way to define the concept of “Therapeutic Use of Self.” The term itself comes to occupational therapy by way of psychotherapy. Another way to define the term is “the use of oneself in such a way that one becomes an effective tool in the evaluation and intervention process,” which involves “a planned interaction with another person in order to alleviate fear or anxiety, provide reassurance, obtain necessary information, provide information, give advice, and assist the other individual to gain more appreciation of, more expression of, and more functional use of his or her latent inner resources” (Mosey, 1986, p. 199).

Imagine working with a client who suffers from diminished mental capacities due to Alzheimer’s or dementia. As you work with them, you experience resistance and some combative behaviors during your visit. Your goal is to get them up and out of bed but they just seem to treat you with disdain and distrust. What would you do?

You could call it quits or you could employ some out of the box thinking and connect with your client. By adopting the Therapeutic Use of Self model, your attitude and response becomes part of the treatment. In fact, your interaction helps you to define the parameters of your client’s responsiveness and you may see expansion of this progress as you continue to utilize the skills of effective communication in your sessions. Humor, patience, flexibility and creativity allow you to get on with whatever program of therapeutic modalities you are planning to use with your client.

Allowing yourself to enter in the model of the world that your client is living in, goes a long way to showing you what to do next. This is Client Centered focus at work! Ask yourself, “What would motivate them to act? What would they already be capable of that could be expanded upon and move them in the direction of where I’d like to lead them? What emotion would they need to feel just prior to taking action in that direction?” It’s always easiest to work with what you’ve already got and teach someone, making use of what they already know.

As therapists, we must embody the teaching and lead from example sometimes. Therefore, whenever you run into a conflict, ask yourself, “what would it be like for me if I were in this client’s shoes?” As it is often said, “go there first!” Once you do, it is much easier to embody the lesson and motivate your client with the Therapeutic Use of Self.

Let’s imagine that you are working with a patient diagnosed with dementia as mentioned earlier in this article. They really don’t want to get out of bed, but it is your responsibility to get them out and involved in some meaningful therapeutic activity. It’s important to strategize your responses with as many pertinent facts as you can gather from the client first. The goal is to positively influence them to choose what’s best for them, using what you’ve learned about them.

If you’ve taken the time to ask yourself the questions in the previous paragraphs, an insightful and creative response might emerge. It might prompt you to take on a more obvious leadership role, with more direct and authoritative language. Or it might just be that you become curious and adopt the qualities of an investigative reporter, getting the scoop about what they feel, so that you can model your responses accordingly. Sometimes there may be a bit dancing necessary to adapt appropriately to your situation. Everyone you work with is unique.

“You are as unique as your fingerprints. There will never be another person exactly like you.” -Milton H. Erickson

If you want what you say to really land for them inside their mind, you’ve got to win their trust quickly and become adept at affecting their feelings. Winning the client’s trust and rapport isn’t very different than a good, heart-centered sales process. In order to sell the idea of following your lead, you’ve got to find out what’s important to them and what emotions drive them to take action. Once you know this, that information can be used to persuade them of the wisdom of choosing to get with the program. Is this manipulative? You bet, and that’s your job! You are using positive manipulation to bring about a therapeutic result, but it is never forced or against their will. You are merely influencing them to make a positive choice for themselves. Any effective therapy involves this to some extent. Just remember that it always begins and ends with respect.

Every person’s map of the world is as unique as their thumbprint.There are no two people alike. No two people who understand the same sentence the same way… So in dealing with people, you try not to fit them to your concept of what they should be. -Milton H. Erickson

Respect for their model of the world allows you insight into their whole way of experiencing the world. Without it, we would be blinded by our own ambitions and forget to connect with our clients. The specific story that they are telling themselves isn’t near as important as what they are feeling and how they are behaving. If you really want to influence their behavior, you will need to remain focused on that.

“There are no resistant clients, only inflexible communicators” – NLP Presupposition

Just about anything and everything the client experiences can be re-purposed and used to help you to help the client. As Milton H. Erickson taught, we can utilize their beliefs, negative feelings, neurotic habits, life circumstances and even their perceptions to mutual advantage.

A comment about from them saying that it’s too cold to get out of bed, could spur a response such as, “Yes! Your body is telling you that it’s too cold, isn’t it? What does that tell you about the condition of your blood circulation right now?” This conversational language pattern encourages a moment of dissociation, allowing them to momentarily separate themselves from the experience of the cold (real or imagined). It also frames the potential benefits of what you’re about to do with them by contrasting the physical need for exercise against their complaint of being too cold. It could be a great opener to talk about the relationship between movement and circulation.

You could take this a step further by saying, “If you were looking at yourself from even farther away, like someone watching you from the outside, what could you notice about your body’s need to… get moving now? (pause for emphasis) Right?” This language pattern dissociates them a bit further in their mind, by having them briefly imagine being in third person. The unusual directiveness of the question possibly encourages the client into an imaginative state, whereby they could be unrestrained by any negative emotion(s) which might have been holding their resistance in place before that moment.

These oddly-stated conversational patterns may seem awkward at first, but mastering them can empower both the client as well as the practitioner in numerous ways. Carefully phrased verbal patterns can shift the client’s awareness into something called a transderivational searchas they are attempting to answer you. This moment of confusion could be valuable if it’s utilized properly by the therapist. Just because confusion is part of the problem, doesn’t mean that it can’t be part of the solution too!

Whatever response you get, is another opportunity to be creative and redirect the attention of the client. You might get an “I don’t know” answer, which could be followed up with, “I know you don’t know, but if you did what would you say?” If you get nothing more but a look of confusion, you could acknowledge that moment and lead them to their next step: “That’s right…and while you’re wandering, you can just find yourself climbing right out of that confusion and place your feet firmly on the floor! We’ve got things to do this morning, don’t we! Let’s go!” (grammar and word choice is intentional, for subconscious effect)

“Until you are willing to be confused by what you already know, what you know will never grow bigger, better, or more useful” -Milton H. Erickson

The Therapeutic Use of Self—or “the conscious use of self”—is a key aspect of the role of the occupational therapist and actually takes precedence over other important aspects of their work as it “includes but is greater than rapport and the art of practice (Mosey, 1986, p. 199).

It’s all about the therapeutic relationship: “the client-therapist relationship is perceived as a fundamental component of the occupational therapy process (Lyons, 1994; Price, 2009).

Ultimately, the best therapists focus on the quality of the relationships with their clients. It is a sacred trust that involves honesty, compassion, dedication and the application of learned principles. If we discount the relationship and simply focus on techniques, the entire process loses much value. Clients are people and people value the investment of time and energy to their care from others. As the relationship builds, so does the trust and their raison d’etre becomes validated as they start feeling empowered to live life again with normal functionality again. It’s amazing to see to quality of life returning to someone who suffered lost capacities due to something unfortunate such as a stroke. It can be hard work getting there, but the results make the journey worth it.

Though there are many aspects we could focus on when looking at therapeutic interactions in coaching and occupational therapy, it is the therapeutic use of self which teaches us about the power of our relationships with the client. In occupational therapy and all therapeutic change-work, it is a metaphorical “Holy Grail” which leads to the “Promised Land”. If we acknowledge the power of our effect upon others, our ability to affect them increases.

Once we’ve mastered the methods and techniques of our art, the real expression comes from embodiment of the principles and application of creativity in our caring for others. We have the opportunity to become beacons of hope and positive influence for those in need, if we just allow ourselves to be.

You use hypnosis not as a cure but as a means of establishing a favorable climate in which to learn. -Milton H. Erickson

The Grand Rounds Lectures are a critical component of Stanbridge College’s program for medical students, including those in the last portion of their Master of Science program in occupational therapy. Stanbridge College is a private institution offering courses in Nursing and Allied Health.

The Masters Program in Occupational Therapy at Stanbridge College is overseen by Janis Davis, Ph.D., OTR | MSOT Program Director and taught by: Eileen Wang, MA, OTR/L – Academic Fieldwork Coordinator – Master of Science in Occupational Therapy Program. For more information about programs offered at Stanbridge College, click on this link: More Info About Stanbridge College.

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