The Intentional Relationship Model

3- Inter personal reasoning

Successful Relationship

Application of the Model Must Be Informed by Core Values and Ethics

The resources of the model are focused on helping therapists better understand both their clients and their own interpersonal characteristics and one helping therapists become more able to monitor and respond to the inevitable interpersonal events of the

case

Enduring characteristics

• They are stable aspect of the client's interpersonal behavior .
• They include, for example, a client’s preferred style of communication, capacity for trust, need for control, and typical way of responding to change, challenge, or frustration.
• They do reflect the client’s personality.

Introduction

Situational characteristics

• Reflect a client acute emotional reaction to a specific situation (typically one that is painful, frustrating, or stressful).
• Situational characteristics may be observed.
• For example, when a newly disable client exhibits sadness or anger or when a client perceive the therapist to have done or said something that is insensitive

The client

• Multi-modal therapists are able to utilize all six of the modes flexibly and comfortably
• According to IRM , a therapist should choose and apply a particular therapeutic mode or set of modes to match the enduring interpersonal characteristics of the client
• Mode shift : interpersonal event in the therapy ; it’s a conscious change in ones way of relating to a client .
• For example, if a client perceives a therapist attempts at problem solving to be insensitive or off the mark, a therapist would be wise to switch from the problem solving to the empathizing mode so that he can get a better understanding of the clients reaction and the root of the dilemma .

Purpose

• Specific way of relating to a client.
• IRM identifies six therapeutic modes: advocating, collaborating, empathizing, encouraging, instructing, and problem solving.
• Therapists naturally use therapeutic modes that are consistent with their fundamental personality characteristics, and they also vary in their range and flexibility.
• Two primary ways vs. multiple therapeutic modes to suit client characteristics and the therapeutic situation.
• Therapists interpersonal style refers to therapeutic mode or set of modes typically used when interacting with the client

The IRM explains how the relationship between client and therapist affects the overall process of occupational therapy and how that relationship can be used to enhance occupational therapy outcomes.

• It is widely recognized in the field that therapeutic use of self is a highly personal, individualized, and subjective process.

• The theory underlying psychotherapy.

• Intentional Relationship Model (IRM) recognizes that the content of occupational engagement in therapy

Theory

The therapeutic relationship as being composed of the following :

1. The client

2. The interpersonal event that occur during therapy

3. The therapist

4. The occupation

2- Therapeutic modes

The client is the focal point of this modal: IRM emphasizes that it is the therapist responsibility to develop a positive relationship with the client.

In order to develop this relationship and respond appropriately to the client, a therapist must work to understand the client situational and enduring interpersonal characteristic

Interpersonal event

“Naturally occurring communication ,reaction, process,task,or general circumstance that occurs during therapy and that has the potential to detract from or strengthen the therapeutic relationship” (taylor, 2008. p.49)

• IRM guides the therapist in managing the interpersonal dynamic between the client and the therapist. The therapeutic relationship function as :

1. A support of occupation engagement

2. A place where the emotional and coping processes associated with the clients impairment and its implications for occupational performance are addressed. .

• A step-wise process by which a therapist decides what to say, do, or express in reaction to the occurrence of an interpersonal dilemma in therapy
• This skill requires vigilance toward the interpersonal aspect of therapy to anticipate dilemmas that might occur

According to IRM , the therapist is responsible for making every reasonable effort to make the relationship work.

The therapist brings three main interpersonal capacities into the relationship :

• An interpersonal skill base
• Therapeutic modes (or interpersonal styles)
• Capacity for interpersonal reasoning

THE THERAPIST

It is Necessary to Keep Head Before Heart

The Therapeutic Relationship

1. Interpersonal skill base

• Continuum of skills that must be judiciously applied by the therapist to build a functional working relationship with the client .
• There are many areas of the interpersonal skills that can be addressed by this model
• These areas depending on therapist experiences, knowledge, and capacities
• Some of these skills will come more naturally while others require significant effort and practice to be developed.

What the process that the therapist monitors the interpersonal event of therapy?

Research and Evidence Base

One cannot assume that as long as one's heart is in the right place, one will naturally react and behave appropriately in therapy.

• IRM is a new model relatively, research on its concepts and application has yet to be developed. As a prelude to developing IRM.
• Taylor and colleagues undertook a national study of therapeutic use of self in occupational therapy.

Interpersonal Reasoning

What the event that affect the client and as you a therapist what your response

Interpersonal reasoning involve steps

Intensify event: challenging aspect of client life style

Or vulnerabilities

Therapeutic responding: process of interpersonal reasoning rely heavily upon therapist

Use of modes and extent of development of their interpersonal knowledge base IRM

Asllison and strong (1994) concluded that good clinical communicators were able to accommodate their interaction to meet their clients’ need as recommended in IRM.

In this study, over 90% of therapists reported that their relationships with clients affected occupational engagement and over 80% felt that therapeutic use of self was the most important skill in their practice and the key determinant of occupational therapy outcomes

Cole and Mclean (2003) found that therapists perceived the therapists relationship as critical to therapy outcomes and emphasized rapport, open communication, and empathy (all components stressed by IRM.

Palmadottir (2006) concluded from her research that occupational therapists needed to have more awareness of how their own attitudes are communicated and acted out in therapy as is emphasized in IRM.

Eklund and hallberg (2001) concluded from their research that verbal interaction was a significant component of the therapeutic relationship ,

The process by which a therapist monitors the interpersonal event of therapy the client unique interpersonal characteristic and her/his own behavior in reflective way to maximize the like hood that the therapeutic relationship will be successful and supportive of the client engagement in occupation

When you developing your interpersonal skills what happen

Helps one promote healthy ,functional relationship with client and other member of the treatment team

Help ensure more positive therapy outcome

• Note:

The therapist must know the strength and weakness for therapeutic interaction

• These finding are consistent with claims in the occupational therapy literature about the importance of the therapeutic relationship.
• The study also found that occupational therapists are frequently challenged to deal with difficult emotion and behaviors in the therapeutic relationship.
• Despite the acknowledged importance of the therapeutic relationship, the vast majority of the practitioners in this study did not feel that sufficient knowledge about the therapeutic relationship and therapeutic use of self exits within the field of occupational therapy

• There views strongly supported the need for IRM to be developed.
• Another important empirical foundation of IRM is Taylors (2008) detailed examination of occupational therapists identified as having exceptional skill in the therapeutic use of self.

The therapeutic relationship is also influenced by characteristics and behaviors that the client and therapist bring to the relationship and by circumstances surrounding the relationship

IRM underscores that the occupational therapist must assume the ultimate responsibility for the relationship, thereby creating a space wherein “a client can be frustrated, or angry without fearing that the relationship will be ruptured”

The therapist must appropriately define and keep the boundaries of the therapeutic relationship and maintain a positive climate of interpersonal relating (trust, mutual respect, and honesty).

• A socially defined and personally interpreted interactive process between the therapies and a client.
• It is socially defined in that the therapist and the client are engaged in an interaction within publicly understood roles.
• The relationship is understood to exist for the purpose of achieving improvement in the client’s situation.(Taylor (2008))

Levels of therapeutic relationship

• Though I did not know it at the time, the difference for Joe on this day was that he was experiencing a severe escalation in fatigue and pain. At this time, the task was not only painful for him, but more importantly Joe was acutely aware that he was not performing the task as well or as quickly as he normally would. Since Joe did not tell me what he was feeling at the time, I had to rely on may own observation of his affect and other nonverbal cues.

• For example, to continue with the activity more independently. Joe generally tackled challenging therapeutic activities with effort and determination. He conveyed a strong work ethic and the desire to improve his ability to participate in daily activities.
• Joe is treatment day typically began with a short, supervised session in which he engaged in a therapeutic activity that required only set-up. On one particular day Joe was participating in an activity focused on grasp and release, using his impaired upper extremity. He had performed this activity on many occasions, which had resulted in his progress. This day, however, an interpersonal event of therapy occurred during the activity.

Example

This “typical” grasp and release activity for him became an emotionally charged therapy task. Joe took of pride in the fact that he had built up an ability to complete this task well and thin certain time frame. In his own mind, he associated his cancer was not progressing. I was soon to learn that any setback in his performance of this task threatened this budding sense of hope, and this is why this particular task was emotionally charged for Joe .

As I observed his performance, I, too noticed his decreased proficiency with the task . He paused more than usual, cast his chair. At anther point he let out a gasp of exasperation. His frustration and disappointment , and likely his worry, were all evident in his face and behaviors. In addition to noticing these nonverbal cues, which I considered as interpersonal event in themselves, I realized that Joe was displaying situation interpersonal characteristic that differed form his usual presentation. He appeared discontent and disappointed. In contrast to his usually buoyant and occasionally cheerful attitude, Joe displayed a sullen affect and avoided making eye contact with me. Different from his typically open and direct communication style, he elected not to tell me about his thoughts or feeling. Moreover, he was over unable to communicate what, if anything, he needed in order to continue with activity. Most importantly, he ultimately gave up during the task, a response that was vastly different thane his usual behiovers, in addition to the direct observation of his performance, indicated that he was struggling at the point in time

1. Macro-level the ongoing enduring rapport and patterns of interaction between client and therapist

2. Micro-level the moment-by-moment therapeutic relationship as influenced by interpersonal events of therapy that have the potential to challenge or enrich the relationship

• Both play a role in the overall process of occupational therapy and they are interrelated

Practice

resources

Joe is a50-year –old Hungarian immigrant who was diagnosed with malignant brain tumors several years ago. He was receiving intensive outpatient occupational therapy service due to impaired function in his right upper extremity. The most noteworthy of Joe enduring interpersonal characteristic were his affect, communication style, capacity to assert need, and response to change or challenge. That is, Joe generally presented as cheerful and friendly smiling another patient and his therapists. He was thoughtful about communication his idea and feeling would often engage in conversation during the therapy. He was not shy about telling people what he needed between sessions. Nor was he reluctant to tell me when an activity was to o easy or difficult or when he needed something positioned

After observing his nonverbal cues and reasoning that he was overwhelmed, I relied on the empathizing mode, as is recommended in IRM. I showed activity-foucsed communication by learning toward him and placing my hand on his arm. I also attempted to show interpersonal focused communication by verbalization to him what I thought he was communication through his expression and behaviors. I tried to label what I observed by saying to Joe, "you seem over whelmed by the difficulty you are having with this activity today”. After he confirmed the accuracy of my statement by giving ahead nod, I stated my concern about his abandonment of the activity since it was atypical behavior for him. These statements served as an opening for Joe to elaborate on how he was feeling and what he was thinking about his current difficulties. We engaged in a discussion that helped me to understand his perception of his poor performance and his concerns that his performance difficulties were a potential sign of the spread of his cancer. As Joe told me about what he had been experiencing and worrying about, I did my best to use the skill of empathic listening, one of the element of therapeutic listening. When it appeared that we came to an understanding of the event and his nonverbal cues indicated that he was no longer overwhelmed, I knew that amide shift was needed in order to proceed with the session. That is I needed to haft to the problem-solving mode in order to discuss with Joe how he should proceed with exploring the possibility that his illness was progressing. After a brief discussion, we decided that Joe would make an appointment to meet with his oncologist to discuss his concerns

The client may bring pre-existing emotional and/or behavioral difficulties into the relationship

Simple events such as the therapist’s unanticipated need to miss an appointment, a misunderstanding about some aspect of therapy, or a personal crisis or medical exacerbation that causes the client to regress can threaten an already tenuous relationship. How the therapist responds to such events has a powerful influence on the final outcome.

• Recognize a clients emotion , reaction , or behavior
• Understand its source
• Consciously and reflectively consider options for how to act
• Monitor the clients response

these resources include the following:

IRM provides guidance as to the modes that are most likely to be successful in responding to different interpersonal characteristics

• Emotions, behaviors, and reactions that mostly emanate from underlying traits of the client are referred to as enduring interpersonal characteristics.
• Both types of client characteristics require a therapeutic response, but the nature and extent of the response will vary depending upon whether a clients interpersonal behavior is situational or more enduring .
• For example , the response to a client who is anxious about a new job would be different from the response to a client who is chronically anxious about any new task or activity.

• materials and procedures for better understanding and monitoring clients interpersonal characteristics
• materials and procedures for therapists to better understand their own modes, interpersonal styles ,reaction ,skills ,and knowledge
• resources for identifying inevitable interpersonal events in therapy
• a format for applying interpersonal reasoning
• guidelines and materials for developing ones interpersonal skill base (conflict resolution)

The ideal a multi-modal therapist whose use of modes reflects a vigilant understanding or the clients unfolding needs rather than ones personal comfort zone

a first step in this process is becoming aware of ones current use of modes questionnaires and exercises are provided to help therapists learn their comfortable and uncomfortable modes.

Taylor (2008) also gives a wide range of examples , exercises , and guidelines for therapists to practice and learn new modes

finally , she provides examples and guidelines on how to select the appropriate mode or sequence of mode for dealing with different clients and situations.

Activity Focusing Must Be Balanced With Interpersonal Focusing

• IRM identifies categories of interpersonal events that are shown in table 10.3 ( taylor, 2008)how the inevitable interpersonal events of therapy are interpreted by the client is influenced by the circumstances of therapy and the clients unique set of interpersonal characteristic .
• IRM provides detailed guidance on positive ways that therapists can learn to recognize and deal with the interpersonal events of therapy and clients reactions to them

Understanding , monitoring, and responding to clients interpersonal characteristic

• By becoming aware of these categories , a therapist can become more attuned to each client's unique interpersonal characteristics.
• An interpersonal characteristics rating scale ( Taylor ,2008 ) can be used to evaluate how clients vary on each these dimensions.
• In additional to being aware of a clients tendency to display certain interpersonal characteristics , therapists must also be vigilant during therapy to

Understanding one's own modes , interpersonal styles , reactions , skills ,and knowledge

• actively seeking to know and understand each clients interpersonal characteristics ( client emotions , behaviors , and reactions that occur in interactions between the client and therapist ) is essential to an intentional and tailored relationship in which the clients feels comfortable.
• as noted earlier , when client's interpersonal behaviors are inconsistent with how they typically interact with others and largely linked to some other external stressful circumstance, they are referred to as situational .

However , taylor (2008) does recommend that therapists :

• IRM emphasizes that self-knowledge and self-discipline are key to becoming an intentional and interpersonally effective therapist .
• A central component of this self-knowledge is developing an awareness of ones own natural tendency to use certain therapeutic modes.
• One therapist may learn , for instance , that he is more inclined toward problem-solving and instructing modes while another may be more comfortable and make use of the empathizing and advocating modes .
• IRM stresses that no mode or therapeutic style (i.e., tendency to use certain comfortable modes ) is inherently superior

IRM identifies 12 categories of :interpersonal characteristics

Identifying and responding to the inevitable interpersonal events of therapy

• Be aware of their dominant modes and their likely impact on clients
• Strive to develop a wider repertoire of mode use
• Achieve greater facility in selecting , utilizing and changing modes according to client needs and the therapy situation

• Communication style
• Capacity for trust
• Need for control
• Capacity to assert needs
• Response to change and challenge
• Affect
• Predisposition to giving feedback
• Capacity to receive feedback
• Response to human diversity
• Orientation toward relating
• Preference for touch
• Capacity for reciprocity

• Identifying and responding to the inevitable interpersonal events of therapy.
• Interpersonal events are distinguished from other therapy events in that they are emotionally charged and ripe with both threat and opportunity .
• Because these events are inherently emotional , therapists and clients alike can be tempted to ignore them or minimize their significance .
• However , if ignored , they can lead to difficulties in the therapeutic relationship and negatively affect occupational engagement .
• On the other hand , if addressed appropriately , these events may lead to positive outcomes that involve feelings such as gratification , fulfillment , satisfaction , or intimacy.

• Activity focusing refers to strategies of responding to interpersonal events that emphasize doing over feeling or relating.
• Interpersonal focusing refers to strategies that emphasize feeling or relating over doing.
• Balance means that the therapist does not rely too much on using activities to avoid direct discussion of interpersonal issues or, by contrast, does not overemphasize discussion of interpersonal issues to the point that it is uncomfortable or distracts the client from necessary occupational engagement.
• The balance between activity and interpersonal focusing various from client to client and over time

Mindful Empathy Is Required to Know Your Client

Mindful empathy is an objective mode of observation in which the therapist comes to feel and understand a client's underlying emotions, needs, and motives, while at the same time maintaining an objective viewpoint" (Taylor, 2008. p. 60).

Interpersonal Self-Discipline is Fundamental to Effective Use of Self

Fundamental Principles

Therapists are responsible for managing and fortifying the therapeutic relationship by attending and responding to ongoing interpersonal feedback from clients.

Interpersonal self-discipline allows a therapist to develop a stable and predictable relationship in which a client can trust the therapist, who remains focused on what the client wants from the relationship and puts personal reactions and expectations aside.

Doing so requires interpersonal self-discipline (i.e., anticipating, measuring, and responding to the effects of ongoing communication with a client).

Grow Your Interpersonal Knowledge Base

Interpersonal communication is complex and requires a range of knowledge and skills such as listening effectively, communicating clearly overcoming basic conflicts and events, and being reliable and predictable.

Critical Self Awareness is a Key to the Intentional Use of Self

Critical self-awareness involve a general knowledge of one's interpersonal tendencies while interacting with clients of different personalities and under different conditions and circumstances.

Enactive use of self also requires ongoing critical awareness, which includes a constant mindfulness about what one is communicating verbally( e.g. choice of word), nonverbally (e.g. positioning of one's body and gestures), and emotionally (e.g., tone, tenor, and volume of voice. and facial expression)

Interpersonal tendencies include one's emotional reactions and behavior(verbal and nonverbal) and how they are influenced by awkward, tense, or stressful situations.

Flexible Applications of Therapeutic Modes

Every therapist has unique interpersonal characteristics derived from innate personality and life experiences.

These characteristics dispose therapists toward a certain therapeutic mode or modes.

Clients differ in what they want within the therapeutic relationship. Some prefer a more formal relationship in which the therapist mainly instructs and gives guidance.

Other clients desired a more personalized connection and emotional support.

Still others wish for an egalitarian and collaborative relationship.

The Intentional Relationship Model

Cultural Competency Is Central to Practice

Differences in gender, age, race, ethnicity, socioeconomic status, religious views, sexual orientation, disability status, and a wide range of other social and cultural dimensions can affect the therapeutic relationship.