The Intentional Relationship Model

AbstractIntroduction: The occupational therapy profession has a long tradition for highlighting the role of the client-therapist relationship for the outcomes of occupational therapy. Despite its perceived value and signicanceamong practicing therapists, a consistent theoretical framework for addressing the therapeutic relationship inoccupational therapy practice was not published until 2008.

Aim: This article introduces the Intentional Relationship Model, a model which conceptualizes the relationalaspects of importance to occupational therapy practice.

Outline of the model: Particular emphasis is placed on describing the therapists tasks and demands forestablishing and sustaining a productive relationship with the client. These demands concern the learning andutilizing of a range of interpersonal skills, the exible and self-reective use of six therapeutic modes, and theprocess of reasoning about the interpersonal events of therapy and how these can be appropriately addressed.

Discussion and implications: In the future, the concepts and the practical usefulness of the model will have to beaddressed in research, education, and clinical occupational therapy practice.

Keywords: the intentional relationship model, therapeutic relationship, use of self, occupational therapy.

Key message: The Intentional Relationship Model directs attention to the interpersonal aspects of theoccupational therapy process. The ultimate goal of IRM is to help therapists improve their relationships withclients and help them provide their assistance to clients more effectively. In practice situations, theoccupational therapist should decide on a therapeutic style or therapeutic mode based on reasoning aboutthe clients interpersonal style and the events of therapy.

BY TORE BONSAKSEN , KNUT VLLESTAD AND RENEE R. TAYLOR

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Use of the therapeutic relationship inoccupational therapy practice

Conflict of interest: There are no reported conflicts of interest related to this article.

Tore Bonsaksen isAssociate Professorat Oslo and Akers -hus UniversityCollege. Email:tore.bonsaksen@hi-oa.no

Knut Vllestad isAssistant Professorat Oslo and Akers -hus UniversityCollege, Depart mentof Occupa tionalTherapy , Prostheticsand Orthotics.

Renee R. Taylor isProfessor atUniversity ofIllinois at Chi -cago, Occupatio -nal TherapyProgram in theUSA.

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Worldwide, occupational therapypractice is concerned with sup-porting clients in their efforts to per-form the everyday life occupationsthat are important to them (AmericanOccupational Therapy Association,2002; College of OccupationalTherapists, 2010; Crepeau, Cohn, &Schell, 2003; Kolsrud, Laberg, &Ness, 2011). By doing this, occupati-onal therapists contribute to clientsparticipation in life and to the rela-ted experiences of health and well-being (Crepeau et al., 2003; Kielhof -ner, 2009). A vast amount of publica-tions points to a general agreementwithin the profession that success inpromoting client participation inoccupations partly relies on the quali-ty of the relationship between the cli-ent and the therapist (Allison &Strong, 1994; Cole & McLean,2003; Eklund & Hallberg, 2001;Palmadottir, 2006; Peloquin, 2003;Peloquin, 1990). Without a basis in apositive and nurturing relationshipwith the client, otherwise well-inten-ded and thoroughly designed treat-ment interventions may be compro-mised. In line with this view of the thera-

peutic relationship as an importantprecondition for productive occupati-onal therapy interventions, there is alongstanding professional traditionfor emphasizing the client-therapistrelationship as one important aspectof the occupational therapy process(Taylor, 2008). Empirically, a recentsurvey in the USA with 568 partici-pants confirmed that occupationaltherapists place a high value on thetherapeutic relationship more than90 percent believed their relationshipwith the client affected the clientsoccupational engagement, and morethan 80 percent believed their use ofself in the client-therapist relationshipwas the most important skill in theiroccupational therapy practice (Tay -lor, Lee, Kielhofner, & Ketkar,2009). As a paradox, however, onlyabout half of the respondents felt thatthey had received sufficient trainingin the therapeutic use of self duringtheir basic occupational therapy edu-cation. Moreover, less than a thirdfelt that there was sufficient knowled-ge about the therapeutic use of self in

the profession as a whole. These fin-dings advocate for a consistent con-ceptual framework, addressing therelational aspects of the occupationaltherapy process, to be introduced. This theoretical article introduces

the recently developed model of thetherapeutic relationship in occupatio-nal therapy, the Intentional Relation -ship Model (Taylor, 2008), and aimsto clarify its key concepts. Undersco -ring the clinical utility of the model,particular attention will be given tooutlining the tasks and demands ofthe occupational therapist in the pro-cess of establishing and sustainingproductive relationships with clients.In conclusion, possible directions forthe future application of the modelare addressed.

The Intentional RelationshipModel

The Intentional Relationship Model(IRM), introduced by Taylor in2008, is the first theoretical outline ofthe therapeutic relationship in occu-pational therapy practice (Taylor,2008). It is not directly concernedwith the professions primary focus ofsupporting the clients occupationalengagement, but explains the relati-onship between the client and thetherapist as one potential preconditi-on for the clients engagement in theoccupational therapy process.

There are several goals related to theuse of this model: First, therapistsshould use it as a tool for self-reflectionto be able to shape and develop theirrelationship with clients intentionally.Second, the model is designed toincrease therapists awareness of theirown contributions to the relationshipwith the client, including an awarenessof their preferred modes of relatingto the client. Third, therapists shoulduse their knowledge of therapeuticmodes in order to expand their reper-toire of modes and in order to useeach of them flexibly, according to cli-ents needs. The ultimate goal of IRMis to help therapists improve their rela-tionships with clients, as this can helpthem provide their assistance to clientsmore effectively.According to the IRM, there are

four variables of importance to theoccupational therapy process (Taylor,2008). These are the client; the inter-personal events occurring within theclient-therapist relationship; the the-rapist and his or her way of respon-ding to the interpersonal events; andthe clients occupation. We willaddress each of these variables in thefollowing, and Figure 1 shows theproposed relationships between them.

The clientThe clients contributions to the the-rapeutic relationship particularly rela-

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Figure 1. The Intentional Relationship Model.

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tes to his or her interpersonal charac-teristics. Interpersonal characteristicsare emotions, behaviors, and reacti-ons that occur in interactions betwe-en the client and the therapist. Theclients interpersonal characteristics atany given time should be viewed asdetermined by a combination of theclients underlying personality traits(enduring characteristics) and impor-tant aspects of the clients current cir-cumstances (situational characteris-tics) (Taylor, 2008).

Enduring characteristics: For a largepart, a persons personality constitu-tes the persons stable and consistentways of perceiving and relating toother people. Each person has anidiosyncratic interpersonal profile,which involves a habitual style ofcommunication, a certain capacity fortrust, and a certain need for control.In addition, the persons personalityinvolves a general orientation to rela-ting to others and a usual way ofresponding to change, challenge andfrustration (Taylor, 2008).

Situational characteristics: Occupati -onal therapists should hesitate toexplain the clients ways of respon-ding to the therapy or to the therapistwith reference to the clients persona-lity. Clients in need of therapy mayhave strong personal reasons to actand respond in ways that are inconsis-tent with their underlying personali-ty. Such reasons may include new orexacerbating illness, symptoms, orim pairments in fact, these are typi-cally the situations that cause thestress that often leads the person intotherapy in the first place. Stressfulsituations give rise to acute emotionalreactions that are specific to the situa-tion, and not to the person. In suchsituations, the stress that the personexperiences may attenuate, change, orintensify his or her typical pattern ofresponse. The therapists interpretati-on of the clients responses as ancho-red in enduring personality traitsand/or in the stressful situation athand helps inform the therapist inunderstanding the client and guidesclinical reasoning towards tailoring anappropriate response (Taylor, 2008). In addition, the clients relations-

hip with the therapist can itself beexperienced as a source of stress. Forexample, if the therapist comes acrossto the client as insensitive or unca-ring, this may cause the client tointeract and relate in ways that he orshe would not normally do. How the-se problems are addressed and resol-ved during the therapy is importantfor the client-therapist relationship aswell as for the clients outcomes fromoccupational therapy.

Interpersonal eventsAn interpersonal event consists of anaturally occurring communication,reaction, process, task, or general cir-cumstance that occurs during therapyand that has the potential to detractfrom or strengthen the therapeuticrelationship (Taylor, 2008, p. 49).In turn, interpersonal events maystrongly influence the clients motiva-tion, goal-orientation, and occupatio-nal engagement. As different persons respond to dif-

ferent things in different ways, thekinds of interpersonal events that mayhave an impact during the course ofoccupational therapy defies definiti-on. One typical example, however,can relate to the client and the thera-pist having a disagreement overappropriate goals for therapy. Theseare issues that need to be resolved inorder to make therapy work. Anotherexample concerns the clients overtexpression of grief or anger during atherapy session. The occupationaltherapist needs to respond appropria-tely to such emotionally challengingevents. The IRM emphasizes that inter-

personal events are, by their nature,unavoidable. Moreover, the therapistshould not try to ignore them whenthey occur, but rather deal with them.Interpersonal events are what happenbetween persons who interact, andwho do so in ways that stimulate, oreven call for, an emotional reaction.The emotional reaction may surfaceat the time when the interaction takesplace, or later upon reflection. Asinterpersonal events are charged withemotion, they should not go unnoti-ced. Ignoring them, or responding tothem inappropriately, may threatenthe therapeutic relationship. Con -

versely, appropriate responding toemotionally charged events can soli-dify the relationship and provide opp-ortunities for the clients learning orchange (Taylor, 2008).

The therapistThe intentional use of the therapeuticrelationship includes the therapistsconsideration of appropriate respon-ses to the interpersonal events occur-ring in therapy. To accomplish this,the therapist should preferably be ableto draw from a large base of interper-sonal skills. According to the IRM,interpersonal skills are summarized innine categories. Some of these skillsdevelop naturally as the person deve-lops, whereas others require conside-rable training to develop and main-tain (Taylor, 2008). The nine inter-personal skills are summarized inTable 1.

The interpersonal skill base: Therapeu -tic communication skills allow theoccupational therapist to establish arelationship with the client characte-rized by caring and understanding.Therapeutic communication skillsinvolve verbal and non-verbal com-munication skills, therapeutic liste-ning, assertiveness, and being able togive feedback to the client andrespond to feedback from the client.Interviewing skills and skills related tostrategic questioning are important inorder to gain sufficient informationabout the client. Establishing relati-onships is necessary for building andmaintaining rapport with clients. Similarly important is the thera-

pists knowledge about the impact offamilies, social systems, and groupsrelevant for the clients current situa-tion, is he or she to be able to workeffectively with these groups. Otherimportant stakeholders in clinical col-laboration can be supervisors, em -ployers, and other professionals, andthe occupational therapist wouldbenefit from learning to cooperateeffectively with them. In direct thera-py with a client, difficult interperso-nal behaviors may occur, and effectiveoccupational therapists are able tounderstand and manage such behavi-ors and their consequences. Onereason for experiencing difficulties in

faglig the relationship with the client can bethe occurrence of an empathic breakor a conflict between the client andthe therapist, and skills in mendingsuch ruptures in the therapeutic rela-tionship is a fundamental interperso-nal skill. The occupational therapist should

be able to uphold and practice profes-sional behavior, including the adhe-rence to professional ethics and valu-es. Finally, the model proposes thatone therapist skill is related to caringfor oneself and caring for his or herprofessional development.

Therapeutic modes: A therapeutic mo -de is a specific way of relating to a cli-ent. For therapists, the most frequent-ly used mode or modes tend to beconsistent with the therapists perso-nality. Therefore, the therapists favo-rite mode defines his or her interper-sonal style in relationship to clients.Performing therapy is most comfor-table when relating in a way that isfamiliar; relating in more unfamiliarways demands a high level of thera-pist self-knowledge in addition to awillingness to change. The goals ofthe IRM include both of these as -pects. Developing as a therapist in -volves being able to use the therapeu-tic modes based on the clients perso-nality and current needs, as opposedto the therapists personal preference(Taylor, 2008). Each mode has itsinherent strengths and weaknesses,and they should therefore be used fle-xibly and with good timing. TheIRM identifies six distinct therapeuticmodes, and an overview is providedin Table 1.The advocatingmode often relates

to an understanding of disabilityemphasizing the environmental barri-ers to occupational participation.Using this mode of relating, the the-rapist will seek to ensure that the cli-ent is provided with access to the vari-ous types of resources they need inorder to participate in desired occu-pations. For example, imagineDaniel, a client with chronic mentalillness who has just started a supporti-ve employment program. He is stres-sed by the new situation and tells thetherapist that he has started hearingmore voices. He has also told the psy-

chiatrist about this, and the psychia-trist has increased Daniels medicati-on. The situation makes him worrythat he may lose his job if the supervi-sor finds out about his increasedsymptoms. A response to this clientwithin the advocating mode can be topoint out to him that he has certainrights to have the workplace accom-modated to his needs. Also, the thera-pist can remind him about the possi-bility of negotiating the problem withthe supervisor if he feels this will benecessary.The collaboratingmode strongly

relates to the principles of client-cen-tered practice, with its emphasis onclient empowerment. Therapistsusing this mode will often involve cli-ents in all aspects of therapy, inclu-ding setting goals for therapy, makingdecisions about courses of action, and

in reasoning about the therapeuticprocess. Imagine once more the caseof Daniel, who was worried aboutlosing his job if the supervisor foundout about him hearing voices. A colla-borative therapist response can be toask the client what he thinks he willneed to do to keep his job, and if hecan set a goal for himself that willdirect his efforts towards staying in it.The empathizingmode concerns

the therapists striving towards fullyunderstanding the clients innerworld, including all facets of his expe-rience. Therapists using this modewill listen vigilantly to the client andbe tuned in to be able to adjust theirapproach rapidly and respond careful-ly to slight changes in the clients af -fect and behavior. Applied to the caseof Daniel, the therapist can use theempathizing mode by acknowledging

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Interpersonal skills Therapeutic modes Interpersonal reasoning

Therapeutic communication

Advocating Anticipate

Interviewing skills andstrategic questioning

Collaborating Identify and cope

Establishing relationshipswith clients

Empathizing Determine if a modeshift is required

Families, social systems,and groups

Encouraging Choose a responsemode or mode sequence

Working effectively withsupervisors, employers,and other professionals

Instructing Draw upon any relevantinterpersonal skills asso-ciated with the modes

Understanding andmanaging dicult inter-personal behavior

Problem-solving Gather feedback

Empathic breaks and conicts

Professional behavior,values, and ethics

Therapist self-care andprofessional develop-ment

Table 1. Interpersonal skills, therapeutic modes, and steps in the interpersonalreasoning process

faglig the difficulties related to experiencingmore symptoms when he has juststarted in a new job. The therapistcan also invite Daniel to tell moreabout the things that he goesthrough.The encouragingmode is characte-

rized by the therapist instilling the cli-ent with hope and courage, so thatthe client will pursue with exploringor performing important occupati-ons. The role of a cheerleader canbe a salient metaphor for this mode,and frequent strategies connectedwith the mode are complimentingand cheering. The clients successesare celebrated with joy. The therapistcan convey an encouraging responseto Daniel by reminding him about atime in the recent past when he had asimilar increase in symptoms. Theproblems at that time were tempora-ry, the therapist may remind him the symptoms eventually faded, andthe fact that Daniel managed to getthrough it back then gives much hopethat he will again now.Therapists using the instructing

mode often educate their clientsabout various topics, and may wellassume a teacher-like style of commu-nication. Clients are provided withclear instructions about, for example,how to perform a specific task, orabout the rationale for the proposedoccupational therapy intervention.The style is characterized by an active,directive, and structured way of rela-ting to the client. Applied to Daniel,an instructing mode of relating can beexpressed if the therapist chooses toremind him how long the psychiatristhas said it may take for medication tobe effective. In addition, the instruc-ting therapist may review with Danielpossible strategies for managing hallu-cinations on the job. Finally, the problem-solvingmode

is based on using reason and logic inthe therapeutic approach. Reasoningas a way of relating can for examplebe used when exploring with the cli-ent a range of options for action, aswell as the potential consequences ofthese actions. Strategic questioning isoften used as a way of structuring thedialogue with the client, and thera-pists using this mode will often relyon logic also when resolving conflicts

in the relationship. A problem-sol-ving response to Daniel can take theform of asking him whether he canthink of any other reasons why hemay lose his job or conversely, whyhe may keep it. A therapist perfor-ming in this mode can also pose fur-ther questions in order to help Danielthink more rationally about his cur-rent job situation.

Interpersonal reasoning: Interpersonalreasoning is an important task thatrequires the therapists attentiontowards the interpersonal aspects oftherapy. The attention is based on theanticipation that problems or dilem-mas might occur in the relationshipwith the client, and that the therapistshould be able to review and evaluatealternatives for therapeutic responsesto such problems (Taylor, 2008).According to the IRM, the process ofinterpersonal reasoning is describedin six steps. An overview of these stepsis provided in Table 1. First, the therapist should anticipa-

te that the inevitable interpersonalevents of therapy may test, challenge,or pose a threat to the therapeuticrelationship. Second, when suchevents occur, they must be accuratelyidentified by the therapist. This ofteninvolves labeling the event, either si -lently to oneself, or aloud to the clientin order to seek access to his or herinterpretation of what just happened.The therapist must also find ways tocope with the event, in terms ofmanaging his or her own emotionalreactions to it, but also in terms ofreflecting about what aspects of theclients behavior can lead to non-the-rapeutic responses commonly expe-rienced are problems related to cli-ents anger or hostility, excessive criti-cism or negativism, and controllingand manipulative efforts. Next, having identified, labeled,

and initially coped with the event, thetherapist should assess whether or nota shift in therapeutic mode is re -quired. Such a shift in therapeuticapproach can often be useful in re -sponding to interpersonal events oftherapy that otherwise may have thepotential to create ruptures in the the-rapeutic bond between client and the-rapist. Mode shifts require a range of

capacities and skills, including thetherapists being knowledgeableabout the different modes and theirinherent strengths and limitations.The therapist must also be able toidentify his or her own mode use inthe mo ment, to reason about whichmode(s) can be better suited as aresponse mode to the situation athand, and to be able to learn andpractice responses that are related tounfamiliar modes.Having considered the need for a

mode shift, a response mode or asequence of modes should be chosenand used with the client. In this pro-cess, the therapist draws upon anyrelevant interpersonal skills associatedwith each of the modes. In addition,the IRM suggests that messages to theclient should be framed within theboundary of one therapeutic mode, asmore complex, many-faceted messa-ges may lose some of their intendedmeanings (Taylor, 2008). As the client defines the quality of

the client-therapist relationship, thetherapist may want to gather feedbackfrom the client on a regular basis, andparticularly following interpersonalevents. The therapist may check inwith the client about his or her per-ception of what takes place in thera-py, including his or her perceptionsof the relationship with the therapist.Following an interpersonal event, theclient may well be asked about his orher feelings about it, and similarlyabout how he or she feels about thetherapists way of managing theevent. This will provide the therapistwith valuable information concerninghow the use of modes is perceived bythe client, and will eventually preparethe therapist for subsequent modeshifts based on the feedback.

The occupationAccording to the ideology of occupa-tional therapy, the therapeutic me -chanisms by which the client achievesor returns to health, mastery, andwell-being are related to his or herengagement in valued and importantoccupations (American OccupationalTherapy Association, 2002; Collegeof Occupational Therapists, 2010;Crepeau et al., 2003; Kolsrud et al.,2011). Promoting occupational parti-

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faglig cipation is, consequently, at the coreof occupational therapy practice(Crepeau et al., 2003; Kielhofner,2008; Kielhofner, 2009). Occupa -tions may include the performing of awide range of activities, such as dres-sing oneself, making a meal, takingthe kids to a ball game, or reading abook. The IRM conceives a soundtherapeutic relationship as a precon-dition for the therapists promotionof occupational engagement in theclient (Taylor, 2008). Without a trus-ting relationship with the occupatio-nal therapist, the client will not, orwill only reluctantly, become engagedin the occupational therapy process.Given a well-functioning relationshipwith the therapist, where the clientfeels safe to explore, practice, and sus-tain new occupations or new waysto perform old ones importantchange can take place (Kielhofner,2008).

Future directionsIn this article, the key concepts of theIntentional Relationship Model aredescribed. The model is focused onthe therapeutic relationship in occu-pational therapy that is, the dyna-mic relationship between client andoccupational therapist throughouttherapy. The importance of this rela-tionship for the clients process andoutcomes from therapy has beenhighlighted in much of the professio-ns existing literature (Allison &Strong, 1994; Cole & McLean, 2003;Eklund & Hallberg, 2001;Palmadottir, 2006; Peloquin, 2003;Peloquin, 1990; Taylor et al., 2009).However, the IRM is the first concep-tual outline that systematically hasaddressed the role of the therapeuticrelationship in occupational therapypractice.On a critical note, some may argue

that the IRM focus on the therapeuticrelationship brings about an attentionshift for occupational therapy practi-ce, bringing the attention closer tothe focus area of psychotherapy. Thisis not the intention of the model.Although the IRM purports to be aconceptual model of occupationaltherapy practice, it reports openlyabout its limitations. The IRM focu-ses on the relational aspects of occu-

pational therapy practice, and not onthe occupation itself. Although thisrelational context is considered highlyimportant for the outcomes of occu-pational therapy particularly incases where the client has mentalhealth problems, or other problemsthat impact the clients relationshipsto others the IRM should always beused in conjunction with other con-ceptual models of occupational thera-py practice (Taylor, 2008). It shouldnot be used as the therapists onlytool for clinical reasoning, but as anadditional model highlighting therelational aspects of therapy. Otheroccupation-focused models shouldalways underpin the practice of occu-pational therapists.The IRM is a relatively new model

of practice. The extent to which itwill have an impact on occupationaltherapy practice depends on severalfactors. The models concepts willhave to be put into use by occupatio-nal therapists in order to verify orquestion their usefulness for clinicalpractice. Are these concepts useful toreason with? Can the model help meimprove my understanding of real lifepractice situations? Does it provideme with tools for changing and deve-loping my way of managing relations-hips with clients? These are questionsthat need to be addressed from a cli-nical practice viewpoint. In addition,assessments based on the model willhave to be tested in order to ascertaintheir validity. A process of investiga-ting the psychometric properties ofselected IRM assessments at theUniversity of Illinois at Chicago, incollaboration with a number of uni-versities worldwide, is currently pro-gressing. The further development and dis-

semination of this model appears tobe timely. The recent survey conduc-ted in USA confirmed the high valuebeing placed on the therapeutic relati-onship by occupational therapists(Taylor et al., 2009). However, abouthalf of the therapists felt they wereinsufficiently trained during basiceducation, and a larger proportionfelt there was insufficient knowledgeavailable in the profession as a wholeabout the use of self in occupationaltherapy practice. This gives reason to

put more energy into researching therole of the therapeutic relationship inoccupational therapy practice, andinto teaching the therapeutic use ofself in basic and advanced occupatio-nal therapy education. q

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