Therapeutic Use of Self: A Nationwide Survey
of Practitioners’ Attitudes and Experiences
KEY WORDS
•  communication
•  education
•  occupational therapy
•  professional–patient relations
•  professional practice
Renee R. Taylor, PhD, is Professor, Department of
Occupational Therapy, University of Illinois at Chicago,
1919 West Taylor Street (MC 811), Chicago, IL 60612;
rtaylor@uic.edu
Sun Wook Lee, MS, OTR/L, is Doctoral Student in
disability studies, College of Applied Health Sciences,
University of Illinois at Chicago.
Gary Kielhofner, DrPH, OTR/L, FAOTA, is Professor
and Wade/Meyer Chair, Department of Occupational
Therapy, College of Applied Health Sciences, University
of Illinois at Chicago.
Manali Ketkar, MS, OTR/L, is Advanced Master’s
Student, Department of Occupational Therapy, College of
Applied Health Sciences, University of Illinois at Chicago.
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Renee R. Taylor, Sun Wook Lee, Gary Kielhofner, and Manali Ketkar
Practitioners’ preparation for, attitudes toward, and experience of the therapeutic relationship and use of self
were explored using a survey study with a random sample of 1,000 American Occupational Therapy Association
members. Participants reported a high value for the therapeutic relationship and use of self; most felt that they
were inadequately trained and that the field lacks sufficient knowledge in these areas. Regardless of practitio-
ners’ age, gender, experience level, setting, treatment intensity, and client impairment, those who placed higher
value on the use of self and had more training related to the therapeutic use of self were more likely to report
interpersonal difficulties and feelings of positive regard for clients and were more likely to report concerns
about clients. The findings suggest that more attention needs to be paid to the therapeutic relationship and to
the therapeutic use of self in education and in research.
Taylor, R. R., Lee, S. W., Kielhofner, G., & Ketkar, M. (2009). Therapeutic use of self: A nationwide survey of practitioners’
attitudes and experiences. American Journal of Occupational Therapy, 63, 198–207.
T hroughout its history, occupational therapy has emphasized the importance of
therapists’ interactions with clients. Although there has been no consistent ter-
minology to refer to therapist–client interactions (Anderson & Hinojosa, 1984;
Ayres-Rosa & Hasselkus, 1996; Cole & McLean, 2003; Eklund, 1996), one of the
most common terms is the therapeutic relationship. Discussions of the therapeutic
relationship commonly address communication, emotional exchange, collaboration,
and partnership between therapists and clients.
The term therapeutic use of self is ordinarily used to refer to therapists’ conscious
efforts to optimize their interactions with clients (Cole & McLean, 2003; Punwar
& Peloquin, 2000). The most widely cited contemporary definition of therapeutic
use of self describes it as a therapist’s “planned use of his or her personality, insights,
perceptions, and judgments as part of the therapeutic process” (Punwar & Peloquin,
2000, p. 285).
Early occupational therapists viewed the therapeutic use of self as a means for
encouraging clients to engage in occupation (Kielhofner, 2004; Schwartz, 2003).
The role of the therapist was to promote confidence about occupational engage-
ment, to function as an expert and guide, and to act an emulator of the joy of
occupation (Bing, 1981; Bockoven, 1971; Dunton, 1915, 1919; Tracy, 1912). In
the middle of the 20th century, the therapeutic use of self was viewed through the
lens of psychoanalytic concepts and seen as a means of achieving changes in clients’
psychological makeup (Azima & Azima, 1959; Conte, 1960; Fidler & Fidler, 1954,
1963; Wade, 1947).
The past 3 decades have witnessed a growing literature on the therapist–client
interaction. Although the term therapeutic use of self is not applied to all of these
discussions, the phenomena they address fall within the scope of the definition noted
earlier. Some authors have written about the importance of collaborative and ­client-
March/April 2009, Volume 63, Number 2
 centered approaches (e.g., Anderson & Hinojosa, 1984;
Ayres-Rosa & Hasselkus, 1996; Hanna & Rodger, 2002;
Hinojosa, Sproat, Mankhetwit, & Anderson, 2002; Law,
1998; Law, Baptiste, & Mills, 1995; Restall, Ripat, & Stern,
2003; Sumsion, 2000, 2003; Townsend, 2003). Others have
emphasized the importance of caring and empathy (e.g.,
Baum, 1980; Cole & McLean, 2003; Devereaux, 1984;
Eklund & Hallberg, 2001; Gilfoyle, 1980; King, 1980;
Lloyd & Mass, 1992; Peloquin, 2005; Yerxa, 1980).
Discussions of the use of narrative and clinical reasoning
have also touched on the need for therapists to comprehend
clients’ perspectives and interact with clients to facilitate
their unfolding life stories (Clark, 1993; Crepeau, 1991;
Fleming, 1991; Kielhofner, 2007; Lyons & Crepeau, 2001;
Mattingly, 1994; Rogers, 1983; Schell, 2003; Schell &
Cervero, 1993).
Although these discussions underscore the value that
occupational therapy places on the therapeutic relationship
and on the therapists’ use of self, they do not constitute a
single approach to conceptualizing either of these phenom-
ena. Rather, they are loosely connected by virtue of common
concerns for how therapists achieve and demonstrate under-
standing, caring, and concern for clients’ perspectives and
experiences in their interactions with therapists.
Empirical Studies of the
Therapeutic Relationship
Only a few empirical studies have been conducted on the
therapeutic relationship or therapeutic use of self in occupa-
tional therapy. These studies have differed widely in the
variables they studied and the methods they used. They also
represent a variety of settings and client groups.
In a qualitative study using focus groups, Allison and
Strong (1994) examined how 23 occupational therapists in
general rehabilitation perceived their use of verbal interac-
tion with their adult clients. They concluded that good
clinical communicators accommodated their interactions to
clients’ needs.
Jenkins, Mallett, O’Neill, McFadden, and Baird (1994)
conducted systematic observations of how eight occupational
therapists communicated with geriatric clients during ther-
apy sessions. They found that more experienced occupa-
tional therapists achieved more mutual participation in the
therapy process.
Eklund and Hallberg (2001) investigated how and why
occupational therapists in psychiatric settings used verbal
interaction with their clients. On the basis of a survey of 292
therapists, they found that verbal interaction was used not
only for assessment and interventions but also in treatment
planning and posttreatment evaluation. They concluded that
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verbal interaction was a significant component of the thera-
peutic relationship and emphasized the need to study and
develop the verbal and the doing aspect of occupational
therapy.
In a survey of 129 practicing occupational therapists
from various practice areas, Cole and McLean (2003) found
that therapists strongly emphasized rapport, open commu-
nication, and empathy as important roles in the therapist–
client relationship. They also found that therapists perceived
the therapeutic relationship as critical to therapy outcomes.
Palmadottir’s (2006) qualitative study explored adult
clients’ perceptions of the relationship with their occupa-
tional therapists in a rehabilitation setting. On the basis of
interviews with 20 adult clients, she concluded that thera-
pists needed to pay more attention to their clients’ occupa-
tional issues and needs, involve them more in a goal-directed
therapy process, and have more awareness of how their own
attitudes are communicated and acted out in therapy.
Norrby and Bellner (1995) attempted to identify barri-
ers to a good therapeutic relationship. They interviewed 16
therapists working with adults in mental health and physical
rehabilitation settings and found that therapists’ concerns
over professional ambiguity and their aspiration to be recog-
nized as professionals sometimes led to an emphasis on pro-
fessional knowledge and authority that conflicted with
achieving egalitarian client–therapist relationships. Norrby
and Bellner (1995) also concluded that therapists with more
self-confidence were able to grow personally and profession-
ally and to achieve better relationships with their clients.
Rosa and Hasselkaus (1996) surveyed by telephone 83 occu-
pational therapists who were practicing nationwide. Their
qualitative analysis concluded that therapists’ personal iden-
tities appeared to combine with their professional identities.
They concluded that it is important to have a sense of “con-
necting” with clients in terms of helping and caring.
Guidetti and Tham (2002) interviewed 12 occupational
therapists who worked on self-care training with clients with
either stroke or spinal cord injury. Their qualitative study
identified several interpersonal strategies, including building
a relationship, establishing trust, motivating clients, and
providing an enabling occupational experience.
Eklund (1996) investigated whether the therapeutic
relationship was related to outcomes in mental health prac-
tice. In an observational study of 20 clients and five occupa-
tional therapists, she found that both therapists and clients
perceived their working relationship as good. However, no
consistent relationships with outcomes were found using a
measure of the quality of the working relationship; both cli-
ents’ and therapists’ perceptions of the extent of client par-
ticipation in the treatment process were related to
outcomes.
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 Although these studies provide only limited findings
about the therapeutic relationship, they do suggest that
therapists sometimes encounter barriers to maximizing the
therapeutic relationship and that therapists differ in their
degrees of success in this area. They also suggest that thera-
pists with greater confidence, awareness of their own thoughts
and feelings, and orientation toward the interpersonal aspects
of therapy may achieve more effective therapeutic
relationships.
Collectively, the studies underscore that there is no sin-
gle way of operationalizing the therapeutic relationship and
the therapeutic use of self. The variables they have examined
include communication, mutuality, rapport, and empathy,
as well as some consideration of how therapist characteristics
(identity, role ambiguity) play out in interactions. Finally,
they suggest that despite the field’s long-term and contem-
porary emphasis on the importance of therapeutic use of self
(AOTA, 2002), little is known about the circumstances of
therapy that require it, how therapists learn about therapeu-
tic use of self, and how they experience and manage the
therapeutic relationship.
Study Objectives
The aim of this exploratory and descriptive study was to
describe occupational therapists’ preparation for, attitudes
toward, and experience of the therapeutic relationship and
use of self. Therefore, the objectives of this study were as
follows:
1. Characterize occupational therapists’ views of the impor-
tance of the therapeutic relationship and use of self for
the process and outcomes of occupational therapy;
2. Identify how occupational therapists acquire skills for
the use of self;
3. Characterize the kind of difficult interpersonal behav-
iors therapists encounter within the therapeutic
relationship;
4. Characterize therapists’ reported thoughts, feelings, and
level of concern about their clients; and
5. Explore relationships between the descriptive character-
istics of occupational therapists (age, gender, experience
levels, practice settings, treatment intensity, and primary
problem of the client population) and their levels of
training in use of self, value for use of self, perceptions
of difficult behaviors, positive regard for clients, and
concern about clients.
Method
A mailed questionnaire was used to elicit information rele-
vant to the study objectives from practicing occupational
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therapists. The study was approved by the Institutional
Review Board at the University of Illinois at Chicago.
Participants
The research participants were practicing occupational thera-
pists residing in the United States who were registered in the
member-sampling database, which is owned by AOTA and
the American Occupational Therapy Foundation. Every
23rd record from a total list of 23,168 AOTA members was
identified. This effort resulted in a systematic random sample
of 1,000 AOTA members from a wide range of practice
specialties and settings; with different levels of education,
training, and experience; and seeing clients of various ages
and presenting problems.
To invite occupational therapists to complete the ques-
tionnaire, each prospective participant was mailed a packet
containing an introductory letter of invitation to participate,
a consent form, and a questionnaire on therapeutic use of
self. Only currently practicing occupational therapists were
invited to participate and included in the analysis.
Measures
Use-of-Self Questionnaire. A self-administered mail sur-
vey questionnaire on therapeutic use of self was developed
by Renne R. Taylor and Manali Ketkar and pilot tested on
a group of 22 occupational therapists. The questionnaire was
then revised on the basis of findings from the pilot study,
additional qualitative criticisms about the questionnaire from
pilot study participants, and a focus group discussion with
pilot study participants.
To create a common frame of reference for the survey,
respondents were provided the contemporary definition of
therapeutic use of self noted at the beginning of this article.
They were instructed to respond to the survey with reference
to this definition. Moreover, questions addressed to the
therapeutic relationship were consistently worded to refer to
the therapists’ relationships with their clients. The question-
naire contained 19 questions and was divided into two sec-
tions. The first part collected sociodemographic information
and descriptive information about the respondents’ educa-
tional levels, practice experience, primary treatment setting,
primary impairments seen, typical length of treatment, and
nature and extent of training in use of self.
The second part of the survey asked respondents about
their perceptions of the importance of the therapeutic rela-
tionship, the difficult interpersonal behaviors they encoun-
tered in practice, and their attitudes toward and concern for
clients.
Procedure. Mailed surveys require systematic follow-up
procedures to ensure acceptable response rates. Thus, we
used standard follow-up methods for survey research (Fowler,
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 2002; Forsyth & Kviz, 2006). Within a week of the initial
survey mailing, a follow-up letter was sent to thank everyone
who responded and to ask those who had not done so to
respond. Two additional mail attempts were made to solicit
participation from those who did not respond. Four weeks
after the initial mailing was sent, a second mailing containing
a replacement copy of the questionnaire, a copy of the con-
sent form, a self-addressed stamped envelope, and a reminder
letter was sent to all nonrespondents. Eight weeks after the
initial mailing, a third mailing containing the same items
was mailed. Three weeks after the third attempt, accrual
ceased, no new questionnaires were processed, and data were
entered into an SPSS database.
Data Analysis. Cases with missing data on any variable
were not included when summing items comprising the five
scales and were eliminated from all analyses using the listwise
deletion method. Descriptive and inferential statistics were
used to analyze questionnaire data. Descriptive analyses
included the assessment of frequency and percentage data
for sociodemographic and descriptive variables and the
respondents’ training and education in use of self, value for
use of self, perceptions of difficult interpersonal behaviors in
clients, and positive regard for clients.
Five scales were formed from the items in the survey.
Table 1 shows the scales along with the operational defini-
tion of each scale.
The five scales were used to explore the relationships
stated in the study objectives. Internal consistency was mea-
sured using Cronbach’s alpha. Coefficients are presented in
Table 1 and ranged from .7 (acceptable reliability) to .9
(excellent reliability). Internal consistency was not measured
for the extent-of-training scale because of its high face valid-
ity and because the scale is a simple tally of types of training
received. Conceptually, there is no reason to believe that
types of training in the use of self in occupational therapy
would converge in any meaningful way.
To explore relationships between the variables of interest
(training in the use of self, value for the use of self, difficult
interpersonal behaviors, positive regard for clients, and con-
cern about clients) and the descriptive variables, bivariate
correlations using Pearson’s coefficient were conducted for
the continuous variable of age; t tests were used for dichoto-
mous variables of gender and primary problem of the client
population; and one-way analyses of variance (ANOVAs)
were used for variables with three or more levels, including
experience levels, practice settings, and treatment intensity.
Partial correlations were used to account for the influence of
the descriptive variables while exploring relationships
between the variables of interest. Bonferroni post hoc tests
were conducted for all the ANOVA analyses to isolate sig-
nificant relationships and to control for Type I error. In
addition to the use of Bonferroni tests, a conservative p value
of .01 was set to designate significance for all analyses to
reduce the chances of Type I error emanating from multiple
univariate comparisons.
Results
Descriptive Characteristics
The response rate was 64%, which is somewhat higher than
that typically obtained from surveys of practitioners within
occupational therapy (Giesbrecht, 2006; Jones, Drummond,
& Vella, 2007; Mu, Lohman, & Scheirton, 2006; National
Board for Certification in Occupational Therapy, 2004). After
excluding noncurrent practitioners, 568 valid participants
remained. Most respondents were women (92%), and the mean
age was 42 years (SD = 11). Most of the sample participants

Table 1. Subscales Created From the Survey Instrument

Scale
Extent of training in therapeutic use of self
Value of the therapeutic relationship or
therapeutic use of self
Extent of interpersonal difficulty experienced
Positive regard for clients
Concern about clients
Note. NA = not applicable.
a
Strongly agree = 4; agree = 3; disagree = 2; strongly disagree = 1.
b
Always/almost always = 4; frequently = 3; sometimes = 2; never/almost never = 1.
Internal Reliability
Operational Definition How Quantified Coefficient
Reported number of ways that the therapist Sum of yes responses to items listed in first NA
learned about therapeutic use of self part of Table 2
Extent to which therapists agreeda on the Sum of responses to items listed in Table 3 .70
importance of the therapeutic relationship
or use of self for therapy process and
outcomes
Reported frequencyb of difficult interpersonal Sum of frequency responses to items in .90
behaviors encountered in practice Table 4
Reported frequencyb of positive thoughts, Sum of frequency responses to items in .70
memories, and feelings about clients Table 5
Reported frequencyb of confused, sad, Sum of frequency responses to items in .70
worried, sorry, or intrusive feelings or Table 6
thoughts concerning clients

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 (77%) had been practicing for >5 years. Most (72%) had a
bachelor’s degree in occupational therapy; 25% had an
entry-level master’s degree, 2% had a certificate, and 1% had
a doctorate in occupational therapy (OTD). Only 9%
reported seeing clients with psychiatric disorders as their
primary client population. Most respondents (91%) were
treating other impairments as their primary diagnoses; motor
or movement impairments were the most common, followed
by sensory, cognitive, perceptual, intellectual, and learning
impairments. Respondents worked in a wide range of treat-
ment settings, with inpatient settings (34%), outpatient
rehabilitation (28%), and school settings (23%) being the
most frequent.
Training in the Use of Self
Frequency and percentage data summarizing the nature and
extent of respondents’ training in use of self are presented in
Table 2. As demonstrated in the table, most respondents did
not take a specific course in use of self during occupational
therapy school but instead acquired their knowledge through
various courses, during fieldwork training, and through
interacting with non–occupational therapist professionals.
Approximately half agreed or strongly agreed that they were
sufficiently trained in use of self upon graduating from occu-
pational therapy school; the other half were less certain.
Fewer than one-third agreed or strongly agreed that suffi-
cient knowledge about the use of self exists in this field.
A t test revealed that respondents whose primary client
population was psychiatric (M = 3.6, SD = 1.6) reported
having a greater number of different types of training in use
of self than those seeing nonpsychiatric (M = 2.9, SD = 1.4)
client populations (t[1, 546] = 13.4, p < .01). No other sig-
nificant relationships with the descriptive variables were
observed.
Value for Use of Self
Frequency and percentage data indicating respondents’ value
for use of self are presented in Table 3. As seen in the table,
most therapists reported a high level of value for the thera-
peutic relationship and the therapeutic use of self in occupa-
tional therapy. More than 90% reported that their relation-
ships with clients affected occupational engagement. More
than 80% believed that therapeutic use of self was the most
important skill in their practice and was the key determinant
of therapy outcomes and that clinical reasoning should
always include use of self. No significant findings involved
the value of the therapeutic relationship or therapeutic use
of self scale and the descriptive variables.
Difficult Interpersonal Behaviors
Frequency and percentage data summarizing respondents’
reports of difficult interpersonal behaviors in clients are pre-
sented in Table 4. The difficult behaviors most frequently
reported included emotional dependence, manipulative
behavior, and attention-seeking or attention-demanding
behavior. At the same time, all of these behaviors were
reported as occurring frequently to always in less than one-
third of the sample.
A t test showed that respondents whose primary client
population was psychiatric (M = 35.1, SD = 6.9) reported
a greater frequency of difficult interpersonal behaviors in
clients than those seeing nonpsychiatric (M = 29.3, SD =
5.7) client populations (t[1, 546] = 58.9, p < .01). In addi-
tion, a one-way ANOVA revealed a significant effect of
treatment setting on respondents’ reports of the extent of
difficult interpersonal behavior in clients (F[4, 536] = 13.5,
p < .01). Therapists working in inpatient settings (M = 32.4,
SD = 6.1) reported a significantly greater number of difficult

Table 2. Practitioners’ Training and Education for the Therapeutic Use of Self (N = 568)
Agree, Strongly Agree
Training Modality Frequency %
I took a class that focused ONLY and SPECIFICALLY on this topic in occupational therapy school. 24 4.3
I hold certification or licensure in counseling or in another mental health discipline. 29 5.2
I sought out expert consultation or supervision of an expert after occupational therapy school. 36 6.4
I sought psychotherapy, and it influenced knowledge in this area. 48 8.5
I took continuing education workshops or courses on this topic. 50 8.9
I learned about it through supervision on the job in an occupational therapy clinical setting. 225 40.0
I gained knowledge from reading about this topic. 259 46.0
I learned about this during my fieldwork experiences in occupational therapy school. 293 52.0
I learned about it through interaction with professionals from other disciplines at my workplace. 315 56.0
This topic was covered in various classes in occupational therapy school. 408 72.5
There is sufficient knowledge available in the field of occupational therapy about therapeutic use of self. 158 28.7
I was sufficiently trained in therapeutic use of self on graduation from occupational therapy school. 285 51.3

Note. Percentages are “valid” percentages that took into account the missing data.

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 Table 3. Practitioners’ Value for Use of Self
Agree, Strongly Agree
Item Frequency %
Across all the clients that I see, my relationship with the client is the most frequently key determinant of the outcome of therapy. 460 82.3
Clinical reasoning should always include issues related to one’s therapeutic use of self. 485 86.9
Therapeutic use of self is the most important skill in my practice as an occupational therapist. 489 87.9
My relationship with a given client affects the client’s engagement in therapeutic activities. 536 95.9

Note. Percentages are “valid” percentages that took into account the missing data.

interpersonal behaviors than did therapists working in out-
patient settings (M = 30.0, SD = 5.8), school settings (M =
27.9, SD = 5.4), and home health care (M = 28.5, SD =
6.1). Bonferroni post hoc testing revealed no significant
differences for community-based settings. No other signifi-
cant relationships involving the descriptive variables were
found.
Positive Regard for Clients
Frequency and percentage data reflecting respondents’ posi-
tive regard for clients are presented in Table 5. Most respon-
dents reported feeling positive regard for clients on a fre-
quent-to-always basis. Most reported frequently to always
feeling good about a compliment from a client, and almost
three-quarters of the sample reported that they frequently to
always reflect positively about their interactions and things
they learned from clients.
A one-way ANOVA revealed a significant effect of treat-
ment setting on respondents’ positive regard for clients (F[4,
536] = 4.2, p < .01). Respondents working in home health
settings (M = 12.6, SD = 1.9) reported a significantly higher
level of positive regard for their clients than did those work-
ing in school settings (M = 11.4, SD = 2.3). Bonferroni post
hoc testing revealed no other significant differences between
the treatment settings, and no other significant findings
regarding the descriptive variables and positive regard for
clients were observed.
Concern About Clients
Frequency and percentage data summarizing respondents’
concerns about clients are presented in Table 6. Findings
indicated that many therapists had frequent concerns about
how to best care for their clients, and some reported that
these concerns frequently interfered with their private time.
More than half of the respondents reported that they fre-
quently to always thought about their clients during family
or leisure time, and almost one-third reported that they fre-
quently to always felt sorry that a client had not made prog-
ress. A quarter of the sample worried about clients frequently
to always, and a little more than one-fifth reported frequently
to always feeling frustrated or sad about clients.
Respondents’ age was negatively associated with their
concern about clients such that younger therapists were sig-
nificantly more likely to experience concern about clients

Table 4. Practitioners’ Perceptions of Difficult Interpersonal Behavior in Clients

Agree, Strongly Agree
Item Frequency %
Critical of occupational therapist’s approach 10 1.8
Showing hostility (i.e., treating occupational therapist in a negative or otherwise abusive fashion) 12 2.2
Questioning of occupational therapist’s knowledge or skills 14 2.6
Resisting occupational therapist’s advice, feedback, or suggestions 27 4.9
Having trouble with rapport or trust 29 5.3
Emotionally disengaged or does not appear invested in therapy 50 9.0
Overly passive 51 9.1
Denying impairment or the extent or nature of impairment 60 10.8
Being unrealistic about expected occupational therapy outcomes 66 11.8
Putting selves down, expressing low self-esteem, or fearing judgment 71 12.7
Hostile or aggressive behavior 77 14.0
Oppositional, resistive, or defiant 88 15.9
Passive or isolative behavior 90 16.4
Overly reliant on occupational therapist as a therapist 108 19.4
Needy, manipulative, or demanding 114 20.5
Manipulative behavior 152 27.5
Dependent behavior 169 30.6

Note. Percentages are “valid” percentages that took into account the missing data.

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 Table 5. Practitioners’ Positive Regard for Clients
Agree, Strongly Agree
Item Frequency
Reflect positively on things you have learned 397
from a client
Enjoy the memory of interacting with a client 415
Feel good about a compliment a client gave me 448
Feel positive regard (i.e., admiration, respect) 479
for a client
Note. Percentages are “valid” percentages that took into account the missing
data.
than were older ones (r = –.3, p < .01). t-test findings revealed
that women (M = 15.1, SD = 2.9) were more likely than men
(M = 13.6, SD = 2.7) to report concern about their clients
(t [1, 549] = 10.6, p < .01). In addition, a one-way ANOVA
indicated that respondents differed in their level of concern
about clients based on their experience level (F[4, 545] =
17.6, p < .01). Bonferroni’s post hoc analysis revealed that
respondents with >20 years of experience (M = 13.7, SD =
2.5) reported fewer concerns about their clients than did prac-
titioners with 11–20 years (M = 15.2, SD = 2.8), those with
6–10 years (M = 15.5, SD = 2.9), and those with 1–5 years
(M = 16.3, SD = 3.1). In addition, practitioners with between
1 and 5 years of experience reported more concerns than those
with 11 to 20 years of experience. Practitioners with <1 year
of experience reported the second highest level of concern
about clients (M = 16.1, SD = 2.8) but did not significantly
differ from the other groups according to the Bonferroni
analysis. No other significant relationships were detected.
Relationships Among Variables of Interest
Partial correlations that considered the potential influence
of therapists’ age, gender, experience levels, practice settings,
Table 6. Practitioners’ Concerns About Clients
Agree, Strongly Agree
Item Frequency
Feel bewildered that you just don’t understand a 32
client’s attitude or behavior
Think about your clients during times you do not 87
want to
Feel frustrated with a client’s attitude, behavior, 120
or lack of follow through
Feel sad outside the therapy session because of a 125
client’s circumstances or struggle
Worry about what might happen to a client outside 142
the therapy session
Feel sorry that a client has not made expected 175
progress
Think about how to better help a client during your 373
own leisure or family time
Note. Percentages are “valid” percentages that took into account the missing
data.
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and primary problem of the client population on the vari-
ables of interest were used to examine the following issues:
% (1) whether therapists who place higher value on use of self
71.4 and have more training related to use of self are more likely
to identify interpersonal difficulties in clients and (2) whether
74.5 therapists with higher value for use of self are more likely to
80.9
have concerns about their clients’ welfare while being more
86.2
likely to feel positive regard for their clients. Given that the
ANOVA revealed no significant relationships between treat-
ment intensity and the variables of interest, treatment inten-
sity was not included in the partial correlation analysis. As
presented in Table 7, respondents’ training in use of self was
positively associated with their reports of difficult interper-
sonal behaviors in clients and with their feelings of positive
regard for clients. Training was not significantly related to
the respondents’ level of concern about clients. Similarly, the
extent to which respondents reported value for use of self in
occupational therapy was positively correlated with their
reports of difficult interpersonal behaviors in clients and their
positive regard for clients. Value for use of self was also posi-
tively associated with level of concern about clients. Although
the correlations were mild to moderate in strength, all the
significant relationships persisted despite the influence of
therapists’ age, gender, experience levels, practice settings,
and primary problem of the client population.
Discussion
This study sought to describe key phenomena related to the
therapeutic relationship and therapeutic use of self. It char-
acterized a sample of 568 occupational therapists in terms of
their training in therapeutic use of self, the extent to which
they valued the therapeutic relationship and the therapeutic
use of self, the level to which they encountered difficult
interpersonal behaviors in the therapeutic relationship, and
their feelings toward their clients. Respondents perceived the
therapeutic relationship as vital to therapy clients’ engage-
% ment in therapeutic activities and to the outcomes of therapy.
5.7 Most therapists considered therapeutic use of self as the most
important skill in occupational therapy practice and as a
15.6
critical element of clinical reasoning. These findings are con-
21.5 sistent with claims in the occupational therapy literature and
22.4 Table 7. Pearson’s Correlation Coefficients for Relationships
Between Training in Use of Self, Value for Use of Self, Perceptions
25.5 of Difficult Interpersonal Behaviors, Feelings of Positive Regard for
Clients, and Concern About Clients
31.5
Difficult Positive
Behavior Regard Concern
66.8
Training in use of self .19* .12* –.03
Value for use of self .14* .18* .12*
*p < .01.
March/April 2009, Volume 63, Number 2
 provide evidence from the perspective of occupational thera-
pists of the importance of the therapeutic relationship and
therapeutic use of self.
All respondents reported experiencing at least some
interpersonal challenges, and some of the respondents
reported frequent interpersonal challenges involving clients.
Therapists seeing clients with psychiatric impairments and
those working in inpatient settings of all types reported the
highest levels of interpersonal difficulties with clients. This
finding makes sense given that some clients with psychiatric
impairments may be more likely to manifest interpersonal
difficulties. Moreover, clients with any type of impairment
who find themselves in an inpatient setting may experience
more stress than do clients in other settings, leading to a
greater likelihood of interpersonal tensions. These findings
underscore the extent to which therapists are challenged to
deal with difficult emotions and behaviors in the therapeutic
relationship. They suggest that research is needed to better
understand how client emotions and behaviors affect therapy
processes and outcomes and how therapists can effectively
manage those feelings and behaviors to optimize occupa-
tional therapy processes and outcomes.
Despite their report of substantially difficult emotions
and behaviors in the therapeutic relationship and their
endorsement of its importance, most respondents indicated
that sufficient knowledge about the therapeutic relationship
and therapeutic use of self does not exist within the field of
occupational therapy. Moreover, only about half of the
sample felt sufficiently educated in the use of self after gradu-
ation from occupational therapy school. Most respondents
received their training in the use of self in various courses
during school. Respondents who primarily see clients with
psychiatric impairments did report having a greater number
of different types of training in the use of self than did those
who see clients with other types of impairments, but thera-
pists sought such training after their initial training. Fewer
than 5% of respondents reported taking a course that focused
solely on the therapeutic use of self, and <10% received
consultation or continuing education during their profes-
sional careers. These findings suggest that consideration
should be given to whether preparation of therapists for the
therapeutic use of self is adequate. They also point to the
potential need for therapists to be supported to continue
their learning in this area beyond basic preparation.
Most respondents reported experiencing positive regard
for their clients on a regular basis. Most regularly felt good
when their clients complimented them, and nearly three-
quarters frequently enjoyed positive memories and reflec-
tions about their clients. Although respondents reported
these feelings regardless of their age, gender, experience lev-
els, treatment intensity, and types of impairments seen, those
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working in home health settings did report higher levels of
positive regard for their clients than did those working in
school settings. The reasons underlying this finding are
unclear. Feelings of positive regard were nonetheless high
across all settings, and no significant differences in positive
regard for clients were found between therapists in other
types of treatment settings.
In addition to having positive feelings about their cli-
ents, respondents reported experiencing concern about their
clients to various degrees. More than half of the sample
reported frequently thinking about how to improve care for
their clients during family or leisure time. One-fifth to almost
one-third of the sample reported regularly feeling frustrated,
sad, and worried about their clients. Taken together, these
findings suggest that most respondents cared very much
about the well-being of their clients, but some frequently
experienced painful and upsetting emotions related to their
clients. Concern about clients was most closely associated
with younger therapists, female therapists, and therapists
with less experience in practice. These results raise the ques-
tion as to whether other critical differences among therapists
led some to report more interpersonal difficulties and con-
cerns about clients than others.
The study revealed several interesting relationships.
When analysis controlled for age, gender, experience levels,
setting, treatment intensity, and client impairment, respon-
dents who placed a higher value on and had more training
related to the therapeutic use of self were more likely to
observe interpersonal difficulties in clients. This finding
points to two potential hypotheses. First, better-trained
therapists and those who place greater value on the thera-
peutic relationship may be more able to recognize and label
interpersonal difficulties. Second, those who encounter more
interpersonal difficulties may be more likely to seek training
in and recognize the necessity for therapeutic use of self.
Further research is required to determine the extent to which
each of these hypotheses is supported.
Therapists with more training and value for therapeutic
use of self were also more likely to feel positive regard for their
clients. Respondents placing higher value on use of self were
more likely to report concerns about clients, but training in
use of self showed no relationship with level of concern for
clients. These findings suggest that higher levels of training
in the use of self may enable therapists to more readily identify
interpersonal difficulties with clients while not feeling par-
ticularly worried, sad, or frustrated in the face of interpersonal
challenges. Given that training in the use of self was not nega-
tively correlated with concerns, however, it is not possible to
argue that more training in the use of self would be likely to
reduce those therapists’ concerns about their clients. Other
variables not explored in this study may be contributing to
205
 some of the respondents’ ongoing concerns about their cli-
ents. More research in this area is clearly needed to explore
the source of concern in this subgroup of practitioners. In
particular, it would be useful to know what degree of concern
is associated with a positive therapeutic relationship.
This study was descriptive and exploratory and had sev-
eral limitations. The findings and suggested interpretations
should be considered preliminary. Although the question-
naire used in this study was pilot tested and valid on its face,
and its scales showed adequate to excellent internal consis-
tency, additional psychometric studies are needed to establish
other aspects of the validity and reliability of the scales created
from questionnaire items. In addition, although the sample
was randomly generated, it does not adequately represent the
entire occupational therapy practitioner population.
Occupational therapists who are not members of AOTA and
who did not volunteer for research were not included.
Moreover, it is likely that responses were biased by the higher
likelihood of inclusion of therapists with a high level of inter-
est in use of self. Even though findings were significant at the
p < .01 level, partial correlation coefficients were mild to
moderate in strength. In addition, some data were missing
because some participants failed to respond to certain items
on the questionnaire. Finally, this survey was designed to
achieve a first, broad examination of issues related to the
therapeutic relationship and therapeutic use of self in a large
national sample. Previous studies were limited in scope and
used small convenience samples. Nonetheless, the survey
methodology used in this sample has inherent limitations.
Many variables of interest to the therapeutic relationship will
require direct observation and intensive investigation of
meanings associated with qualitative methodologies.
Despite its limitations, this study served to introduce
some critical considerations for the role of the therapeutic
relationship and the therapeutic use of self in occupational
therapy. Respondents clearly value and care for the well-
being of their clients and consider their relationship with
clients and their therapeutic use of self to be critically impor-
tant for what their clients gain from therapy. At the same
time, they characterize their field’s knowledge and their
training on these topics as inadequate. The findings suggest
that the field could benefit from an increased focus on the
role of therapeutic use of self in classroom education, field-
work training, continuing education, and research.  s
Acknowledgments
Financial support for this project was provided through the
University of Illinois at Chicago Department of Occupational
Therapy.
206
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