and Feedback
One of the most critical aspects of occupational therapy involves the ability to provide clients with structure, direc- tion, and feedback in a way that they can understand it, per- ceive it as constructive, and follow through with it. Guiding clients in these ways serves to relieve any feelings of anx- iety they might be having and also communicates that the therapist is being thoughtful about his or her plans for the session. At the most fundamental level, any of the follow- ing activities may be required to guide a client sufficiently. • Setting a basic temporal framework by informing or
reminding (if appropriate) the client of expectations for attendance, the regularity of the scheduled appoint- ments, and/or the time allotted for each session. • Educating the client of the purpose and potential utility
of therapy.
• Using goal setting as a means to track progress and assess outcomes.
• Educating the client about your preferred approach to practice or theoretical framework, if indicated. • Encouraging the client to provide feedback.
• Informing or reminding the client that you are willing to make adjustments in your approach or interpersonal style based on feedback.
• Introducing to the client what is planned for each ses- sion at the beginning of the session—even if what is planned simply involves asking the client what he or she would like to work on that day.
• If several activities are planned for the session, the ther- apist should describe all that is planned and provide the client with a rough estimate of the time frames within which each activity or task is planned.
• Occasionally checking in with the client to monitor his or her experience of therapy.
• Describing your expectations regarding the client’s role, responsibilities, and behavior in therapy.
• Projecting an attitude of competence.
• When facing sensitive or vulnerable clients, informing them explicitly about your preferred interpersonal modes and their potential limitations (e.g., “I tend to be the type of therapist who prefers to do more listening than talking. But some people feel lost if I listen too much. Would you give me some feedback so I can be sure I am giving you what you need?”)
Many clients naturally conform to the social expecta- tions and cultural norms of the client–therapist relationship within a given setting. For example, in many hospital set- tings in the United States, clients expect therapists to pro- vide a fair amount of structure, direction, and feedback as part of competent care. However, for clients new to a local culture or for those who are more sensitive and vulnerable, good timing is important when providing instruction and guidance. The therapist must determine when, how often, and to what extent to introduce structure, direction, and feedback into the therapeutic relationship. This is best accomplished by continually monitoring the interaction to assess whether the client is seeking guidance and/or open to receiving guidance. When determining client receptivity or indications that more guidance is needed, points to con- sider include:
• Is the client asking questions?
• Does the client lack confidence about what he or she is doing?
• Does the client appear uncertain, anxious, or nervous? • Does the client respond more positively when guidance
is provided?
In addition to assessing receptivity and need, there may be some occasions when a client requires guidance for safety reasons or to ensure that a certain standard of care is achieved. Closely monitoring the client enables the therapist to time the introduction of guiding activities appropriately and reduce the chance that these activities will encourage dependence or be perceived as overbearing, controlling, or critical (Fig. 8.6).
An important aspect of providing clients with struc- ture and direction involves providing them with feedback. Regardless of whether the feedback is intended to be pos- itive or negative, the true nature of any type of feedback is that it is a form of judgment. Providing feedback always carries the potential to make the client feel vulnerable, embarrassed, or evaluated. Thus, providing feedback must be approached with care, and it should always be provided in a way that is straightforward and easy to understand. Table 8.3 contains some helpful hints to keep in mind when providing clients with positive and negative (con- structive) feedback.
In occupational therapy, the focus of feedback typi- cally involves the client’s occupational performance. How- ever, the IRM recommends that feedback of an interpersonal nature is also provided to clients as part of an occasional conversation between the therapist and client about how the client is experiencing the therapeutic rela-
tionship. Thus, occupational therapists should also be prepared to provide clients with feedback about their inter- personal behavior during therapy just as clients are expected to provide therapists with such feedback.
All of these efforts require confidence and assertive- ness, which comprise what the IRM labels a take-charge
attitude on the part of the therapist. A take-charge attitude
involves expressing a confident, assertive, and, when
appropriate, emotionally self-protective demeanor with clients—particularly clients who test boundaries, are anx- ious, or prefer structure and direction. The following char- acteristics may reflect a therapist’s take-charge attitude. • Remaining emotionally centered and managing any
anxiety related to your knowledge or performance as a therapist
Chapter 8 Therapeutic Communication 169
FIGURE 8.6 When conducting therapy in a pool, it is vital that Kathryn Loukas pro- vide adequate instruction and structure to ensure a client’s safety
Table 8.3 Tips for Providing Clients with Feedback
Positive Feedback
When praising a client, comment on or describe a specific behavior (e.g., You’ve gotten that clasp to work”) rather than making a more generalized statement, such as “well done” or “great job.” This guideline also applies when providing feedback of an interpersonal nature. Rather than stating, “I enjoy working with you,” explain why you enjoy working with people or what qualities you appreciate about them.
• Use more generalized statements with parsimony. • Never describe a behavior as “perfect” because it encour-
ages clients to strive for an unrealistic level of performance. • Avoid comparisons to other clients or to famous people
when providing positive feedback. It robs the client of the chance to experience the accomplishment as an individual.
• Unless the client has put in an unusual amount of effort or accomplished something rare and exceptional relative to his or her abilities, the emotional tone of the feedback should be guarded.
• As a general rule, the amount of positive feedback should, at minimum, double the amount of negative feedback provided to a client.
• At the same time, be careful not to over-rely on positive feedback as a means of motivating a client or its impact and sincerity may wear off.
• If a client does not respond well to positive feedback, stop providing it. Instead, encourage the client to share his or her self-assessment of performance more often during therapy. If the client’s self-assessment is unrealis- tic, work with it using strategic questioning (covered in Chapter 10).
• Being adequately prepared for the session and rehears- ing your plans for therapy before beginning, if necessary • Using a confident tone of voice and speaking clearly
and loudly enough
• Assuming a confident body posture • Feeling confident about what you are saying • Making eye contact
• Focusing on making the client feel at ease
• Acting as narrator (describing what will happen next) and emotional buoy (checking in and pausing to assess the client’s experience) when necessary
• Not hesitating to maintain the structure, limits, and boundaries of the therapy
• Being adequately self-protective around clients who are behaving in inappropriate or abusive ways.
Regardless of the setting, assuming a take-charge atti- tude promotes a client’s confidence in the therapist and serves to establish the therapist’s role as the professional in situations where it is necessary and appropriate to estab- lish such a role.
Summary
One of the most telling indicators that your communica- tion with a client has been therapeutic and successful is the
feeling that you are able to communicate with the client in a way that is predictable, straightforward, honest, and comfortable. Feeling that a client is complex or difficult to understand is a sign that additional work on communica- tion is needed within the relationship. This may or may not be possible depending on the client’s abilities and toler- ance for communication.
This chapter provided a detailed review of six prag- matic aspects of therapeutic communication that are vital to establishing and maintaining an intentional and effec- tive client–therapist relationship. It provided a series of guidelines to ensure that therapists feel knowledgeable and confident about their communication skills. Alone, these guidelines do not ensure that a successful relationship will unfold. As with other guidelines provided in this book, therapists should first consider the client’s unique interper- sonal characteristics, any interpersonal events that have occurred during therapy, and the overarching social and physical contexts that surround the communication that is taking place. As mentioned at the beginning of this chap- ter, the Activities section contains an exercise and two self- rating scales designed to facilitate self-evaluation and supervision in the practice of therapeutic communication. Considerations presented in Chapter 9, which includes a focus on cultural competence, should also be incorporated into your thinking about how to achieve effective commu- nication with a client.
Table 8.3 Tips for Providing Clients with Feedback (continued) Negative (Constructive) Feedback
• State the feedback in a clear, straightforward manner. • State the main point of the feedback rather than including
other, more peripheral issues.
• When giving constructive feedback, focus on one issue at a time. It decreases the risk of overwhelming clients, so the clients can focus their energy on that single issue. • Avoid being indirect or vague about the feedback. Overpro-
tecting clients in this way can lead to confusion about the nature of the feedback, a decreased impact of the feedback, or anxious thinking (e.g., “My therapist must think it’s really awful because she can’t even tell it to me straight”). • Set aside a specific time for feedback in the session (e.g., a
wrap-up period at the end of the session). Clients should be prepared for this part of the session in advance (i.e., at the beginning of therapy or at the beginning of each session).
• If a specific time for feedback is established, ask the client for a preference regarding his or her desire to hear con- structive versus positive feedback first. This provides a
greater sense of control over the vulnerable situation of having to receive feedback.
• You can preface constructive feedback by pointing out strength, but only do this if it is sincere. Avoid prefacing constructive feedback with defensive or protective state- ments, such as, “You’re good at remembering the turn sig- nal, but you need to work on changing lanes” or “I don’t mean to criticize your approach, but.…” or “I hope this doesn’t sound too harsh but,…”
• Avoid comparisons or using others as examples when provi- ding constructive feedback.
• Check in with clients to determine how they experienced receiving the feedback (e.g., ask what they took away from the feedback, how it affected their desire to persist, whether it changed their feelings toward you, whether it provoked any new worries, or whether they found it useful). • Remain as emotionally neutral as possible when providing
constructive feedback. Be particularly careful that facial expressions do not reveal anxiety, disappointment, or irritation.
Bidirectional communication—communication that
does feel reciprocal to the therapist because, at mini- mum, it involves some indication that the client has received the communication. More typically, bidirec- tional communication involves an ongoing give-and- take during which both client and therapist may independently initiate and maintain sharing of thoughts and feelings.
Emotional modulation—adjusting the extent to which
one’s verbal communication is marked by emotional- ity in tone of voice and choice of words according to the situation at hand and one’s estimation of the client’s preference and level of tolerance for emo- tional intensity.
Empathic listening—recounting, accepting, and affirm-
ing any perception or experience a client offers.
Guided listening—strategic approach in which a client
attempts to limit, structure, or organize what the client is saying by making one or more clarifying state- ments.
High-context communication—places less emphasis on
explicit verbal description of events and more empha- sis on the context surrounding what is being said, such as the emotional tone or inflection of voice or other events in the broader social environment.
Low-context communication—places more emphasis on
the literal spoken word and less emphasis on inflec- tion, tone of voice, or to the context that frames the communication. People from low-context cultures typically do not hypothesize about what was left unsaid or pay as close attention to subtle changes in inflection or tone.
Nonverbal communication—not based in a formally
recognized spoken or signed language. It includes sounds, tone of voice, facial expression, body pos- tures, movements, and gestures.
Summary statement—a brief statement that reflects the
main points of what a client has said that does not involve asking questions, interpreting, or attempting to structure or guide the client’s conversation in any way.
Striving for understanding—a cyclical process that is
central to empathic listening. It involves making a summary statement, receiving feedback from the client regarding its accuracy, and, if necessary, making a corrective summary statement that reflects more accurate understanding.
Take-charge attitude—expressing a confident, assertive,
and, when appropriate, emotionally self-protective demeanor with clients—particularly clients who test boundaries, are anxious, or prefer structure and direc- tion.
Therapeutic communication—characterized by leader-
ship, responsibility-taking, empathy, and intentionality on the part of the therapist.
Therapeutic listening—therapist’s efforts to gather
information from a client in such a way that it pro- motes greater understanding, validation, and support.
Unidirectional communication—communication that
does not feel reciprocal to the therapist because it is initiated and sustained by the therapist without any apparent response from the client.
Verbal communication—use of a formally recognized
spoken or signed language.
171
GLOSSARY
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The exercises in this section are designed to improve