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The Intentional Relationship Occupational Therapy and Use of Self: Occupational Therapy and The Use of Self 1st Edition, (Ebook PDF
The Intentional Relationship Occupational Therapy and Use of Self: Occupational Therapy and The Use of Self 1st Edition, (Ebook PDF
The Intentional Relationship Occupational Therapy and Use of Self: Occupational Therapy and The Use of Self 1st Edition, (Ebook PDF
The Intentional
Relationship
Occupational Therapy and Use of Self
F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com
Copyright © 2008 by F. A. Davis Company. All rights reserved. This product is protected by copyright. No part of it may be
reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying,
recording, or otherwise, without written permission from the publisher.
As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies
undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in
accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or
omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the con-
tents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards
of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check prod-
uct information (package inserts) for changes and new information regarding dose and contraindications before administering
any drug. Caution is especially urged when using new or infrequently ordered drugs.
All identifying information pertaining to the client cases presented in this book has been altered to protect clients’ identity and
confidentiality. Additionally, certain case content has been fictionalized or merged with examples of other cases so that no indi-
vidual client can be identified. Some of the photographs representing clients in this book are photos of models or actors serving
in the roles of clients.
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00Taylor(F)-FM 11/5/07 1:45 PM Page iii
This book is dedicated to the exceptional therapists whose work was featured in this book.
Generously, they contributed their time, personal reflections, and revealing stories of practice
to serve the interest of education and knowledge development in this under-recognized area
of occupational therapy.
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Preface
This book emerged from an ongoing curiosity and a fair amount of frustration in trying to locate a detailed,
comprehensive, and integrated textbook on therapeutic use of self specific to the field of occupational therapy.
As a professor teaching in this area, my interactions with students and practicing occupational therapists
inspired me to learn more about the interpersonal aspects of practice. As a practicing psychotherapist, I was
also interested in learning how I might blend knowledge from the field of psychology with existing occupa-
tional therapy knowledge as it pertains to the therapeutic relationship.
I began this inquiry by conducting a nationwide survey of 568 practicing occupational therapists ran-
domly selected from a membership database provided by the American Occupational Therapy Association
(Taylor, Lee, Kielhofner, & Ketkar, 2007). The objectives of this study were to determine the degree to which
occupational therapists value the client-therapist relationship, to identify variables that challenge the client-
therapist relationship, and to summarize the interpersonal strategies that are currently being used to respond to
such challenges. Results from this survey revealed that, across practice settings and client populations, prac-
ticing occupational therapists are frequently encountering clients who are demonstrating a wide range of emo-
tional, behavioral, and interpersonal difficulties. Most experienced occupational therapists place a high priority
on their interactions with clients but at the same time feel that their training in this area could have been more
sophisticated and comprehensive. The findings from this study confirmed the need for a text addressing these
issues for use by educators, students, and practitioners of occupational therapy at various levels of develop-
ment.
In preparing to write this book, I first reviewed the occupational therapy literature in order to get an idea
of the historical terrain of thinking about therapeutic use of self in the field. There is a rich history of thought
as well as changing ideals regarding what constituted effective therapeutic use of self at various times in his-
tory. As an educator and a practitioner, I am fully aware that there often exists a gap between the ideals
expressed in literature on a topic and what actually occurs in everyday therapeutic encounters. Consequently,
I sought to shape the contents of this book around practitioners’ expressions of the dilemmas and challenges
they face in therapeutic use of self as well as their descriptions of the way they attempt to manage these cir-
cumstances. Additionally, I decided to look for instances of excellence in therapeutic use of self in occupa-
tional therapy that could be shared with practicing occupational therapists, occupational therapy assistants,
educators, fieldwork supervisors, and students of occupational therapy.
This quest took me across the globe where I extensively interviewed and observed occupational therapists
who were nominated by their peers as being uniquely talented in terms of their ability to relate to a wide range
of clients. This journey taught me volumes about therapeutic use of self in occupational therapy, and my goal
is to share what I have learned with you in this book.
Renée R. Taylor
v
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Acknowledgments
This book would not have been possible without the ongoing support of Gary Kielhofner, who not only believed in the ideas
behind the book but also provided some of the international linkages necessary to include the work of therapists from diverse
nationalities and cultures. Also critical to the energy behind the production of this book were its acquisition editors, Christa
Fratantoro and Margaret Biblis of F.A. Davis who inspired me to think expansively about use of self. Special thanks goes
to Christa, an editor whose enduring support, creative suggestions and feedback, and ongoing belief in a novel approach
kept me going. I would also like to thank Denise LeMelledo, Deborah Thorp, Carolyn O’Brien, and Berta Steiner for their
time and care in producing this book. Finally, special thanks to the following occupational therapy students whose intelli-
gent in-class questions and critical editorial feedback helped to refine the presentation of the contents of this book. In par-
ticular, I’d like to thank Emily Ashpole, Robin Black, Joel Bové, Kim Daniello, Kelly Doderman, Barbara Flood, Mark
Kovic, Anne Plosjac, Abigail Tamm-Seitz, Rachel Trost, Jennifer Utz, Angie Vassiliou, and Debbie Victor.
vii
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Foreword
Literally speaking, a foreword heralds in other words. Dictionary definitions describe a foreword’s aim as introductory. If
asked to choose one word to herald in this book and introduce occupational therapists to its merits, I would choose the word
well-considered. And because I have been asked to say more than one word, I’ll elaborate on my meaning.
This book is well-considered because its focus on the therapeutic use of self is timely and crucial within health care
systems struggling against pressures to compromise good intentions and relations. Taylor’s model of the intentional rela-
tionship reminds practitioners that the use of self in occupational therapy needs both theoretical and practical attention. Her
background as psychotherapist and her role as occupational therapy educator give her a unique vantage point for consider-
ing, creating, and proposing such a model.
Taylor’s work draws both power and credibility from research that explores the stories and experiences of occupational
therapists thought by their peers to possess relational artistry. From various cultures and locations, these therapists share
insights into their successful interactions. In modest ways, these master therapists offer wisdom from which practitioners of
all ages and career stages can benefit.
Itself well-considered, this book will foster consideration among its readers. Taylor’s reflective exercises invite the
development of values essential to the therapeutic use of self. We know that interpersonal skills learned in the absence of
values that nurture them fall short of being therapeutic. Use of self that is conscious requires reflection sufficient to develop
an awareness of personal traits, intentions, and actions. Use of self that is therapeutic presses past such awareness, asking
that practitioners enact the respect and empathy that honor human dignity. Because it invites individuals to consider their
interactions within the moral context of professional lives, the book is a call to mindfulness.
Although an enormous step in itself, understanding of the human need for respect and empathy is not enough. Such
understanding must be paired with solid learning of effective approaches to meeting that need. This book fosters such learn-
ing through open discussions of behaviors that cause empathic breaks and through practical guidelines for meeting personal
challenges found in daily practice. Because students hunger for such knowledge, this book will have educative power.
I have spent much time in thought, writing, and teaching about the therapeutic use of self. I value work on the topic
that is well-considered. This book is such a work. Taylor and I share the belief that the therapeutic use of self is the
essential stuff of occupational therapy rather than its “fluff.” Promise and power lie within this book, and I am pleased to
herald it in.
Suzanne M. Peloquin, PhD, OTR, FAOTA
ix
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Contributors
Kristin Alfredsson Ågren, MScOT, RegOT Stephanie McCammon, MS, OTR/L
Dagcenter Valla University of Illinois Medical Center
Linköping, Sweden Chicago, Illinois
x
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Reviewers
Bette R. Bonder, PhD, OTR/L, FAOTA Terry L. Jackson, MS, OTR, LCDC
Associate Dean Coordinator of Education
Occupational Therapy Rehabilitation Sciences
Cleveland State University University of Texas Medical Branch
Cleveland, Ohio Galveston, Texas
Linda S. Fazio, PhD, OTR/L, FAOTA, LPC Victoria P. Schindler, PhD, OTR, FAOTA
Associate Professor Associate Professor
Occupational Therapy Occupational Therapy
University of Southern California Richard Stockton College
Los Angeles, California Pomona, New Jersey
xi
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xii Reviewers
Contents
PART I Theoretical Foundations and
Guidelines for Practice
1 The Changing Landscape of Therapeutic Use of Self
in Occupational Therapy: Historical Overview . . . . . . . . . . . . 3
2 What Defines a Good Therapist? . . . . . . . . . . . . . . . . . . . . . 19
3 A Model of the Intentional Relationship . . . . . . . . . . . . . . . . 45
4 Knowing Ourselves as Therapists: Introducing the
Therapeutic Modes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
5 Knowing Our Clients: Understanding Interpersonal
Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
6 Challenges to Client–Therapist Relationships: Inevitable
Interpersonal Events of Therapy . . . . . . . . . . . . . . . . . . . . . 117
7 Navigating the Challenges: Therapeutic Responding
and Interpersonal Reasoning . . . . . . . . . . . . . . . . . . . . . . . . 135
xiii
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xiv Contents
Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
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PA RT I
Theoretical Foundations
and Guidelines for Practice
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CHAPTER 1
3
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been addressed throughout the field’s history. Ideas about ment era (Bing, 1981; Bockoven, 1971). Moral treatment
how therapists should interact with clients have changed as was a humanitarian approach that emphasized the facilita-
the field’s conceptualization of its practice has been trans- tion of self-determination through engagement in everyday
formed. Examining these different perspectives on thera- tasks and activities. Consideration and kindness were put
peutic use of self provides an important backdrop for forward as essential interpersonal values. Supporters of
understanding where to begin when conceptualizing the moral treatment also argued that all activity prescriptions
use of self in contemporary occupational therapy. should be based on in-depth understanding of the client’s
Historical analysis has identified three distinct eras preferences and interests (Bing, 1981).
in occupational therapy, characterized as paradigms
(Kielhofner, 2004). The earliest occupational paradigm Early Occupational Era
reflected the humanistic ideas and practices of the field’s When occupational therapy emerged during the 20th cen-
founders. This paradigm built on the ideas of earlier Euro- tury, its leaders emphasized the humanistic approaches of
pean moral treatment. It focused on the individual’s expe- moral treatment (Kielhofner, 2004; Schwartz, 2003). Cen-
rience of doing and on his or her capacity and motivation tral to the thinking during this era was that the therapeutic
to function during interaction with physical and social relationship served as a means by which to encourage
environments. This first paradigm was replaced during the engagement in occupation. The field’s early leaders recog-
mid-20th century by a paradigm of inner mechanisms that nized that the success of therapy depended on the ability of
ushered in concern for addressing clients’ underlying the therapists to persuade or motivate clients (who often
impairments. Rooted in the medical establishment, this were in negative frames of mind) to undertake the occupa-
paradigm sought to correct internal failures of body and tions they were being offered as therapy.
mind. During the latter part of the 20th century a new, con- One early leader, Susan Tracy, argued that the thera-
temporary paradigm returned the field to its initial focus pists should appeal to the intrinsically attractive and satis-
on occupation. As we will see, each of these eras had its fying nature of activities. She saw the therapeutic role as
own particular approach to the therapeutic use of self. one of suggesting possibilities and finding inviting ways to
present opportunities for action. Tracy, along with another
Moral Treatment early founder of occupational therapy, Dunton, empha-
Nascent descriptions of therapeutic use of self were intro- sized the importance of occupational therapists being
duced in Europe in the late 1700s during the moral treat- skilled craftspeople who could serve as positive role mod-
01Taylor(F)-01 11/5/07 1:51 PM Page 5
M osey (1981, 1986) described the conscious use of self as deceitful ways toward clients. Instead, artfulness referred to
the ability to deliberately use one’s own responses to clients as selecting aspects of one’s own personality, attitudes, values,
part of the therapy. She characterized use of self as a “legiti- or responses that were predicted to be relevant or helpful in a
mate” skill across all frames of reference. To select appropriate given situation. In turn, therapists were expected to control or
ways to respond to a client, the therapist had to possess self- suppress those aspects of self that were not appropriate for the
awareness, empathy, flexibility, humor, honesty, compassion, situation. According to Hagedorn, therapists were not expected
and humility. to be perfect; instead, they were expected to be aware of their
Denton (1987) similarly described use of self as conveying strengths and limitations, sensitive, honest, and genuine with
an attitude of respect and acceptance to clients so self-esteem clients. Therapists were also expected to manage stress effec-
could be restored. Self-esteem could also be enhanced by the tively and to have personal integrity.
way in which a task or activity was presented to the patient. Cara and MacRae (1998) defined therapeutic use of self
In addition, a therapist was considered effective in his or as developing an individual style that promotes change and
her use of self if he or she succeeded in modeling charac- growth in clients and helps furnish them with a corrective
teristics of a mature, competent, and admirable person for emotional experience. A corrective emotional experience is
the client. one in which a therapist’s behavior toward a client during ther-
Schwartzberg (1993) defined therapeutic use of self as apy contradicts the way others have behaved toward the client
comprising understanding, empathy, and caring. Effective use in the past and demonstrates to the client that he or she is wor-
of self was defined as remaining neutral but engaged, accept- thy of caring and empathy.
ing the client as he or she is, being tolerant and interested in Punwar and Peloquin (2000) defined the therapeutic use of
the client’s painful emotions, and being able to interpret the self as a “practitioner’s planned use of his or her personality,
client’s expectations of therapy accurately. insights, perceptions and judgments as part of the therapeutic
Hagedorn (1995) defined therapeutic use of self as the art- process” (p. 285). This definition was also used in the Ameri-
ful, selective, or intuitive use of personal attributes to enhance can Occupational Therapy Association’s Occupational Therapy
therapy. Hagedorn clarified that the notion of an artful use of Practice Framework (American Occupation Therapy Associa-
self should not be misconstrued as behaving in artificial or tion, 2002).
els for standards of performance and appreciation for pate in occupations, demonstrate standards of performance
crafts (Dunton, 1915, 1919; Tracy, 1912). Dunton (1915, in sportsmanship and craftsmanship, and emulate the
1919) and two other founders, Meyer (1922) and Slagle enjoyment and satisfaction that came from doing things.
(1922), underscored the importance of understanding the Thus, during the early occupational era, the therapeu-
personalities of clients so therapists would know what tic relationship was one in which the therapist served as:
activities were likely to appeal to those clients.
• Expert, or guide, in the performance of therapeutic
In addition to appealing to clients’ innate dispositions
activities, such as arts, crafts, and sports
and using the intrinsic attraction to occupations, another
• Role model for occupational engagement
approach was to appeal to the client’s sense of the impor-
• Emulator of the joy of occupation
tance of participating in therapy. For example, Haas
• Instiller of confidence
(1944) thought it important to instill faith in the client con-
• Creator of a positive physical and social milieu
cerning the therapeutic process. He recommended that the
physician introduce each client to the occupational therapy To a large extent, the therapist’s use of self was to
director to underscore the value of occupational therapy and set the stage for a client to wish to engage in therapeutic
to build the patient’s confidence in the treating therapist. occupations and to have a positive experience when doing
At this time, the physical and social environments so. The therapeutic relationship required the therapist
were also emphasized as client motivators (Bing, 1981; to serve as a kind of master of ceremonies who orches-
Kielhofner, 2004). Thus, the therapist functioned to ensure trated the environment and the unfolding process of occu-
that the physical context and social milieu was attractive pational engagement. The therapist also needed to get
and inviting and that it embodied a positive esprit de corps, to know the client through interactions and interviews,
order, and utility. Interpersonally, the occupational thera- thereby learning how to appeal to the person’s innate inter-
pist behaved in ways that would invite the client to partici- ests and personality.
01Taylor(F)-01 11/5/07 1:51 PM Page 6
Era of Inner Mechanisms 1959; Fidler & Fidler, 1954, 1963). The second perspec-
Beginning during the 1940s, the second, mechanistic par- tive, heavily influenced by the work of Frank (Box 1.2)
adigm replaced the earlier humanistic one. This new per- used activities to establish a therapeutic relationship that
spective focused occupational therapists on remediating would permit the person to develop healthy means of
the internal biomechanical, neuromuscular, and intrapsy- resolving intrapsychic conflict and fulfilling needs. The
chic mechanisms of the body and mind that influenced following quote illustrates this approach.
function (Kielhofner, 2004). During this time, there was an
The effective therapeutic approach in occupational therapy
important change in emphasis on the role of the therapeu-
today and in the future is one in which the therapist
tic relationship (Peloquin, 1989a). utilized the tools of his trade as an avenue of introduc-
First, this paradigm included the emphasis on elimi- tion. From then on his personality takes over. (Conte,
nating pathology, borrowed from the medical model. 1960, p. 3)
It also included medicine’s ideas about expertise and
authority; these had a strong influence on occupational Given this new emphasis, the occupation or activity
therapy’s view of the use of self. In this framework, thera- lost its unitary importance (Kielhofner, 2004). Instead, the
pists were expected to assume an impersonal and profes- central focus was on the cathartic and corrective relation-
sional attitude toward clients while at the same time ship between therapist and client.
commanding respect, demonstrating exceptional compe-
tence, and conveying a hope for cure (Wade, 1947). Tact,
self-control, listening skills, impersonal objectivity, good
judgment, and the ability to identify with a patient were Box 1.2 Jerome Frank
emphasized as “personality qualifications” of a good I n 1958 during the mechanistic era, Jerome D. Frank,
therapist (Wade, 1947). a psychiatrist, introduced the term “therapeutic use of
During this era, occupational therapy was also self” to the field of occupational therapy. Frank (1958)
heavily influenced by psychoanalytic (i.e., Freudian and introduced psychiatry’s definition of self as a term that
Neo-Freudian) concepts. Emotional, psychiatric, and inter- encompasses every aspect of personality development
personal difficulties were considered aspects of internal and interpersonal behavior. Frank held that the develop-
pathology that needed to be treated using approaches that ment of a client’s healthy self can be derailed by incon-
focused heavily on the relationship that existed between sistent or derogatory parental attitudes, constitutional
the therapist and the client. It was at this time that the term variables (innate temperament), and physical impair-
ments. He further argued that these interruptions in nor-
“therapeutic relationship” first emerged.
mal development of self resulted in what was referred to
According to this new view, it was important for the as a “pathological self-structure.” In relationships, a
occupational therapist to attend to how a client behaved pathological self-structure can manifest in one of two
toward activities within the therapeutic relationship in ways: It can result in a restricted or overly rigid use of a
order to understand the client’s inner motives, interper- small set of interpersonal strategies, or it can result in a
sonal feelings, and relationships with others. For example, diffuse self that has not built adequate self–other bound-
the type of product a client chose to make in therapy and aries and responds to the demands of all others and all
the way the client went about the activity were viewed as situations without discrimination. In either case, Frank
shedding light into the client’s inner motives and feelings argued that the mechanism of repairing a client’s frag-
toward the therapist or others. Such factors as the client’s mented self structure involved the self of the therapist.
That is, the therapist must use his or her self as a mecha-
choice of color, degree of dependence on the therapist, and
nism for repairing a client’s damaged self. Thus, a thera-
preference for different procedures or tasks were all win- pist’s self structure needed to be strong enough to endure
dows into the client’s psyche. threats wrought by the demands and projections of a
A range of ideas was put forward about the nature of client’s pathological self. In addition, Frank held that it
the therapy during this period, but there were two domi- was important for the occupational therapist to show
nant themes. The first argued that the client would achieve competence; resist the need to reassure; act clearly, con-
catharsis through acting out unconscious desires and sistently, predictably, spontaneously, and flexibly; and
motives while performing activities and simultaneously remain ambiguous at times to force the client to cope
gaining insight into these underlying issues through dis- with stress and manage problems independently.
cussion and relating with the therapist (Azima & Azima,
01Taylor(F)-01 11/5/07 1:51 PM Page 7
Both approaches saw activity as augmenting the talk It was acknowledged that this balance varied from patient
that took place in psychotherapy. Importantly, they carried to patient.
a very different connotation As evident in the ideas
about the interpersonal role of these and other seminal
of the therapist from the pre- Whereas the therapist’s contributors of the time, the
vious era. Whereas the thera- closer relationship with med-
pist’s role was previously to role previously was to icine and support for the
appropriately orient the
client to occupations that
appropriately orient the medical model was reflected
in all aspects of occupational
were used as therapy, this
new framework argued that
client to occupations that therapy practice. In the spe-
cialty area of psychosocial
the relationship between the were used as therapy, this occupational therapy, the
therapist and the client was practice of occupational ther-
the key dynamic of therapy. new framework argued that apy was becoming strikingly
These ideas, which were
first developed in psychiatric
the relationship between similar to the practice of psy-
chotherapy. This, in conjunc-
settings, became the domi-
nant way of thinking about
the therapist and the client tion with the recognition
that occupation had lost its
the therapeutic relationship was the key dynamic place as the key dynamic
throughout the entire field. of therapy, led some of the
Thus, during the inner of therapy. key contemporary leaders
mechanisms era, the thera- to reevaluate the field’s iden-
peutic relationship was viewed as: tity and direction (Kielhofner, 2004; Schwartz, 2003;
Shannon, 1977; Yerxa, 1967).
• A central mechanism for change
• A means by which to understand a client’s unconscious
motives, desires, and behavior toward others Return to Occupation
• An avenue through which an individual could achieve Beginning during the 1960s, Reilly (1962) was the first to
catharsis through acting out unconscious desires and notice that the field of occupational therapy was drifting
motives and gain insight into issues that were at the away from a focus on occupation and away from its origi-
core of pathological feelings and behaviors nal values, which were based on concepts of moral treat-
ment. Moreover, the psychoanalytical/neo-Freudian focus
When relating to clients, the therapist was expected to on the therapeutic relationship was seen as having “side-
demonstrate: lined” the central role of occupation (Kielhofner and
• Competence Burke, 1977). The view that the therapeutic relationship
• Professionalism was the key dynamic of therapy was rejected in favor of
• Impersonal objectivity occupational engagement as the true dynamic. Once again,
• Hope the therapist was viewed as a proponent of occupational
• Tact engagement who must use a variety of strategies to make
• Self-control occupations appealing and to support the therapy process.
• Good judgment
• Identification with the patient
Although some of these interpersonal behaviors may Contemporary Discussions
appear contradictory (e.g., identification with the patient
versus maintaining interpersonal objectivity), they were
of the Client–Therapist
not viewed as such at the time. According to the views of Relationship
this era, the ideal therapeutic relationship involved striking
an appropriate balance between having compassion for Alongside this contemporary emphasis on occupation,
a patient and acting in an optimally therapeutic manner. new discussions concerning the client–therapist relation-
01Taylor(F)-01 11/5/07 1:51 PM Page 8
ship have emerged (Cara & MacRae, 2005; Cunning- In addition to care and planning in relationships,
ham-Piergrossi & Gibertoni, 1995). For example, the respect for diversity and cultural sensitivity in practice
occupational therapy literature has argued that a collabora- were also introduced during the contemporary era.
tive relationship that is egalitarian and empowering of Although this area is in need of continued development,
clients leads to improved treatment outcomes (Anderson & cultural competence and awareness of the potential for
Hinojosa, 1984; Ayres-Rosa & Hasselkus, 1996; Clark, personal biases are considered fundamental to building
Corcoran, & Gitlin, 1995; Hinojosa, Anderson, & Strauch, effective relationships (Bonder, Martin, & Miracle, 2001;
1988; Hinojosa, Sproat, Mankhetwit, & Anderson, 2002; Lloyd & Maas, 1991, 1992; Wells & Black, 2000).
Townsend, 2003). As can be readily seen, a variety of contemporary
In addition, caring, empathy, connection, personal descriptions of the conditions necessary for an effec-
growth, and effective verbal and nonverbal communica- tive therapeutic relationship have been put forward. From
tion skills have been characterized as important qualities these numerous ideas, three major themes can be gleaned
for successful occupational therapy practice (Cole & in contemporary discussions of the client–therapist rela-
McLean, 2003; Devereaux, 1984; Eklund & Hallberg, tionship.
2001; King, 1980, 1994; Lloyd & Maas, 1991, 1992;
Peloquin, 2005). There has been a particularly strong • Collaborative and client-centered approaches
emphasis on the appreciative and empathic process by • Emphasis on caring and empathy
which the therapists come to truly understand clients’ life • Use of narrative and clinical reasoning
stories and to feel deep respect for and trust in the clients’
The remainder of this section summarizes the key
perspectives on their experiences (Hagedorn, 1995;
concepts in each of these thematic areas.
Mosey, 1970; Peloquin, 1995, 2005; Punwar & Peloquin,
2000). Some have argued that therapist self-knowledge,
self-awareness of behavior, and the ability to self-evaluate Collaborative and Client-
or reflect on one’s practice are prerequisites for inter- Centered Approaches
personal sensitivity and the capacity for greater under- In contrast to the mechanistic era when the field empha-
standing of a client’s narrative (Hagedorn, 1995; Mattingly sized professionalism, objectivity, and a more analytical
& Fleming, 1994; Schell, Crepeau, & Cohn, 2003; Schon, approach to the relationship, a strong value of the contem-
1983) (Box 1.3). porary era has been that of collaboration, mutuality, and
client-centered practice.
that therapists can seek to readjust these imbalances by knowledge about how best to approach the child’s disabil-
facilitating client control over decision-making and by ity, and fewer opportunities to receive positive
encouraging the client to become actively involved in reinforcement for good parenting skills. Because of this
problem-solving about his or her own situation (Hagedorn, potential for rifts and power differentials in the therapeutic
1995; Townsend, 2003). In support of this approach, a relationship, a number of researchers recommend that
number of occupational therapy writers have incorporated therapists employ collaborative strategies to enable service
the ideas of Schon (1983), who contrasted two types of recipients to build a sense of their own self-efficacy as
contracts that characterized the therapeutic relationship: parents or caregivers (Anderson & Hinojosa, 1984; Clark
the hierarchical professionalism typical of the inner mech- et al., 1995; Hanna & Rodger, 2002; Hinojosa et al., 2002;
anisms era and what he labeled a “reflective contract” in Rosenbaum, King, Law, King, & Evans, 1998). This spirit
which the client assumes control, becomes more educated, has been reflected in the literature on family-centered
and joins with the professional in solving problems related care (Hanna & Rodger, 2002; Rosenbaum et al., 1998).
to his or her situation. Rather than presuming total and These strategies (Anderson & Hinojosa, 1984; Hanna &
complete expertise, Schon (1983) encouraged therapists to Rodger, 2002; Rosenbaum et al., 1998) emphasize self-
think critically about their experiences and behaviors both efficacy as one of the most valued anticipated outcomes
in the midst of performing therapy and once the practice (Baum, 1998).
session ended. Similar collaborative approaches have been applied
The collaborative approach has also been discussed to a wide range of occupational therapy clients of all ages.
with regard to relationships with parents of pediatric For example, Clark et al., (1995) researched the interper-
clients in occupational therapy (Anderson and Hinojosa, sonal behaviors of two occupational therapists interacting
1984; Hanna & Rodger, 2002). The rationale behind with caregiver-clients. Therapist behaviors were summa-
this approach is that some parents of children with disabil- rized in terms of four categories: caring (being supportive,
ities may feel undermined or undervalued by therapists friendly, and building rapport); partnering (gathering
who focus too much on direct therapy with the child reflective feedback and seeking and acknowledging input
and assume an expert stance in the therapeutic relation- from clients); informing (gathering, explaining, and clari-
ship. Parental feelings of vulnerability may stem from fying information); and directing (providing advice and
difficulties accepting the fact a child is disabled, lack of instruction) (Fig. 1.2).
In sum, the literature suggests that collaborative rela- 13 guiding principles that enable a client’s engagement in
tionships are characterized by: occupation within the therapeutic relationship (Law,
Polatajko, Baptiste, & Townsend, 1997). The following
• Open and comfortable communication and discussion
key themes can be described as cutting across these 13
• Highly supportive approaches that convey respect and
guiding principles and are held as priorities for the
trust in the client’s perspectives, strengths, and ways
client–therapist relationship:
of coping
• Consideration of client diversity and unique perspec- • An orientation to and value for the client’s perspective,
tives which includes the client’s values, sense of meaning,
• Establishment of shared goals and priorities natural ways of coping, and choice of occupation
• A clear goal to address the client’s difficulties together • A strengths-based perspective in which clients are
in partnership encouraged to problem-solve and make decisions, iden-
tify needs and set goals, envision possibilities, challenge
Self-Awareness and Collaboration themselves, and use their strengths and natural commu-
nity supports to succeed
In addition to emphasizing client self-efficacy, a number of
• Communication that involves client education, collabo-
writers have argued that therapist self-awareness is essen-
ration, and open and honest discussion.
tial for effective collaboration (e.g., Anderson & Hinojosa,
1984; Hagedorn, 1995). Specifically, therapists are urged The principles of client-centered practice (more
to recognize, control, and correct potentially nontherapeu- recently referred to as enabling occupation) have been
tic reactions to clients that might emerge from unresolved described as representing an ethical stance by occupational
conflicts or their own experiences of being parented in therapists because they are based on democratic ideas
negative ways (Anderson & Hinojosa, 1984). of empowerment and justice (Townsend, 1993, 2003).
Other occupational therapy researchers have ex- According to its founders, the ultimate aim of client-
panded the definition of collaboration to include the for- centered practice is enablement (Law et al., 1997). Enable-
mation of personal-professional connections with clients ment comprises a number of therapist behaviors that result
(Ayres-Rosa & Hasselkus, 1996; Prochnau, Liu, & Boman, in people having the resources and opportunities to engage
2003). These connections are described as incorporating in occupations that shape their lives. These behaviors
one’s own life experiences into one’s understanding of the include facilitating, guiding, coaching, educating, prompt-
client. These connections also involve reciprocal giving ing, listening, reflecting, encouraging, or otherwise collab-
and sharing between client and therapist (Prochnau et al., orating with clients (Law et al., 1997) (Fig. 1.3).
2003). Acknowledging and drawing on one’s personal In summary, the ultimate functions of collaborative
reactions to the helping process in a constructive way and and client-centered approaches to the therapeutic relation-
caring for patients at a fundamental human level have been ship are to increase feelings of self-efficacy and ultimately
described as means of deepening the process of collabora- to enable clients to perform occupations that hold personal
tion with clients (Ayres-Rosa & Hasselkus, 1996). significance. Collaborative and client-centered approaches
continue to influence practice with a wide range of client
Client-Centered Approach populations in vastly diverse treatment settings throughout
Client-centered practice is a formal orientation to practice the world. The next section describes a second major trend
that emphasizes collaboration and considers clients as concerning the client–therapist relationship in the field of
active agents in the therapy process (Law, 1998; Law, Bap- occupational therapy.
tiste, & Mills, 1995). This practice supports and values
clients’ knowledge and experience, strengths, capacity for Emphasis on Caring and Empathy
choice, and overall autonomy. Clients are treated with Whereas the collaborative and client-centered approaches
respect and considered partners in the therapy process. emphasized those aspects of the therapeutic relationship
Although a range of more nuanced descriptions of client- that have to do largely with power dynamics, the empha-
centered practice exist in the literature (e.g., Restall, Ripat, sis on caring and empathy focus more on the affective
& Stern, 2003; Sumsion, 2000, 2003), the most widely dimensions of the therapeutic relationship. They are dis-
recognized proponents of client-centered practice describe cussed below.
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DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI
I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.