From a person-centered perspective, the best source of knowledge about the client is the

Client-Centered Therapy

Client-centered therapy has yielded positive effects across five studies. In client-centered therapy, children are encouraged to express themselves openly while the therapist listens supportively and encourages the children to accept their feelings and gain greater self-awareness. This therapy has been examined in both individual and group formats and has demonstrated efficacy across a wide range of ages. In one study of client-centered therapy for anxiety, involving African American and Hispanic children, investigators reported treatment effects that were smaller than in the studies including only white children. In addition, none of the studies involved participants with an anxiety disorder diagnosis, instead focusing on children with subclinical levels of anxiety, and none included children with comorbidity. Thus, it is not clear whether this intervention would be effective with children from minority groups or with those experiencing more severe anxiety.

Client-centered therapy

Client-centered therapy, sometimes referred to as person-centered therapy, was introduced by Carl Rogers in the 1940s. It was a substantial departure from the traditional psychoanalytic therapies of that time. Rogers initially called his approach non-directive therapy and proposed that the therapist’s role was not to direct or instruct the client but to assist the person in understanding his or her own experience of the world and promote positive change through a trustworthy relationship [Brammer, Shostrom, & Abrego, 1989; Krech, Crutchfield, & Livson, 1969]. To accomplish this, the therapist has to hold the person in positive regard. In other words, the therapist has to respect and empathize with the client.

The basic tenets of client-centered therapy are highly compatible with PsyR and have influenced the field. Client-centered therapy is based on the belief that people will engage in activities leading to positive growth and development if given the opportunity [Krech, Crutchfield, & Livson, 1969]. This belief is consistent with the PsyR value of optimism that everyone has the capacity to recover, learn, and grow. Client-centered therapy asserts that the opportunity for growth exists within relationships that offer empathy, positive regard, and genuineness [Brammer, Shostrom, & Abrego, 1989]. In PsyR, we know that the quality of the person-practitioner relationship is crucial to recovery and rehabilitation. Here, too, the relationship is an egalitarian one, based on empathy, positive regard, and acceptance.

Client-centered therapy focuses on the person’s perception of his or her present circumstances and assists the person in identifying his or her own answers to problems or barriers [Brammer, Shostrom, & Abrego, 1989]. PsyR practice also focuses on the individual’s current aspirations, concerns, and challenges rather than on rehashing past experiences. An important technique used in client-centered therapy is reflecting back the thoughts, feelings, and experiences that the client has communicated. This technique demonstrates empathy, helps clarify issues that are personally important to the person, and keeps the focus on particular issues that the client wants to work on. PsyR practitioners also use techniques inspired by Rogers, usually called reflective responding or active listening [Carkhuff, 2009]. Finally, client-centered therapy places the major responsibility for successful change on the client [Krech, Crutchfield, & Livson, 1969]. In PsyR, we also emphasize the value of self-determination in helping individuals achieve personal life goals.

The work of counseling psychologist Robert Carkhuff, author of The Art of Helping, now in its 9th edition [2009], has been a great help to many PsyR professionals. Carkhuff’s writings help to simplify the helping process of client-centered counseling techniques into comprehensible steps that are easily understood by PsyR practitioners who may not be licensed counselors or therapists. An example is the skill of physical attending that enables the practitioner to use a set of specific nonverbal techniques, such as facing the person squarely, leaning forward slightly, and making eye contact to convey empathy [Carkhuff, 2009].

Client-centered therapy is an approach to psychotherapy based on a belief that the client is best able to decide what to explore and how. It is unique in a field where the therapist characteristically acts like an expert who knows how to resolve the client's problems. Psychologist Carl R. Rogers first described this new approach in a talk in 1940. He published verbatim typescripts of his treatment interviews, in contrast to the prevailing subjective accounts of therapy. This provided data for studying therapy objectively, and paved the way for the field of psychotherapy research. Rogers and his students developed methods of classifying client statements and counselor responses, and of measuring self-regarding attitudes. The concept of self emerged as a central construct of personality organization. As his theory, practice, and research developed, Rogers hypothesized that a relationship characterized by genuineness, unconditional positive regard, and empathy would result in a self-directed process of growth. Client-centered therapy broadened into a ‘person-centered approach,’ applicable to groups, education, and conflict resolution.

Therapeutic Intervention

Rogerian client-centered therapy is nondirective and emphasizes therapeutic or helping relationship. A helping relationship, according to Rogers,72 requires that the therapist be [1] accepting of the client as he or she is [unconditionally], [2] empathic [able to place himself or herself in the client's shoes and to experience reality as perceived through the client's personal frame of reference], and [3] congruent [able to model genuineness in verbal and nonverbal communication]. Thus Rogers felt that central to the therapeutic relationship was behaving naturally which “seemed to help his clients more than acting as a scientist with specialized knowledge” [p. 79].7

This relationship consists primarily of the therapist communicating empathy and acceptance to the client, then using the skills of responding, summarizing, and interpreting to help the client do in-depth self-exploration, leading to insight and action that results in expression of the actualized self.68 The process of therapy can be summarized diagrammatically [Figure 3-2].

6.2 Goal Setting and Motivational Enhancement

Motivational interviews and motivational enhancement interventions provide a wide range of client-centered therapies in which patients set their own goals and manage their motivation toward these goals. Counselors evoke patients’ intrinsic motivation to change, help them to explore and resolve ambivalence, and consolidate a personal decision and plan for change [Miller and Rollnick, 1991; Smedslund et al., 1996]. These techniques develop a focus in a patient's life other than their addiction and improve their commitment to behavioral changes. Motivational interventions help subjects to control their craving and maintain their abstinence by augmenting self-referential processing, salience attribution to abstinence, and inhibitory control. Positive effects of these interventions on craving could be attributed to salience network and ECN [Ewing et al., 2011].

Person-Centered Therapy

Created by Carl Rogers, this is known as nondirective counseling, client-centered therapy, or Rogerian psychotherapy. The nondirective nature of this method provides evidence that the client, rather than the counselor, can help direct the treatment process by evoking self-change. The counselor–client dynamics invests trust in the client to move in a positive direction, provided that the counselor demonstrates appropriate skills: active listening, genuineness, and paraphrasing. A practitioner must be nonjudgmental and avoid giving advice. This supportive role will help clients feel accepted and allow them to understand their feelings. This humanistic therapy acknowledges and focuses on conscious perceptions rather than some therapist’s presuppositions and ideas regarding “unconscious” mindsets.

Person-centered therapy most often demands more responsibility from the client. An “actualizing tendency” in every living organism is the survival instinct: this internal dynamic leads people toward growth, development, and realization of their fullest potential. Person-centered therapy is a positive, directional form based on release and support.

9 Enduring Influence

Major factors in Rogers' impact on psychology and the helping professions were his personal example, longevity, and prolific writings. He presented a vivid role model of the person-centered approach for almost six decades, demonstrating his theories through teaching, lecturing, live demonstrations and workshops, and audio-visual recordings. By all accounts, he embodied his theories by being an exceptional listener and communicator and a decent, honorable person. He wrote 17 books and over 200 professional articles and research studies. Millions of copies of his books have been printed, in over 60 foreign language editions. His most popular book On Becoming a Person [1961], written for both a professional and general audience, continues to spread his ideas.

Critics of Rogers' work have argued [sometimes fairly, sometimes not] that client-centered therapy is superficial, unworkable with some populations, and unmindful of recent advances in behavioral, drug, or alternative therapies; that Rogers' views on human nature are unrealistically optimistic and underestimate human evil; that encounter groups and humanistic psychology have fostered widespread selfishness, narcissism, and moral permissiveness; and that Rogers' experiments with organizational change were naive and counter-productive. Nevertheless, in the USA, although no longer a central figure in popular psychology, Rogers' influence endures. In 1972, he was awarded the American Psychological Association's Distinguished Professional Contribution Award, becoming the first psychologist to receive the organization's highest scientific and professional honor. The citation read:

His commitment to the whole person has been an example which has guided the practice of psychology in the schools, in industry and throughout the community. By devising, practicing, evaluating and teaching a method of psychotherapy and counseling which reaches to the very roots of human potentiality and individuality, he has caused all psychotherapists to reexamine their procedures in a new light. Innovator in personality research, pioneer in the encounter movement, and respected gadfly of organized psychology, he has made a lasting impression on the profession of psychology.

After Rogers' death in 1987, the greatest new interest in his work has been outside the USA, including Russia, Eastern Europe, and Latin America. As a Japanese counselor explained in the 1960s, Rogers helped ‘teach me … to be democratic and not authoritative.’ His life's work demonstrated how supportive, growth-producing conditions can unleash healing, responsible self-direction, and creativity in individuals and groups in all walks of life. As countries strive to resolve intergroup tensions and practice self-government and self-determination, many have recognized in Rogers' work not only useful methods for helping professionals, but a positive, person-centered, democratic philosophy consistent with their national aspirations. Rogers eventually recognized the political implications of his theories and methods and explored these in Carl Rogers on Personal Power [1977]. At Rogers' memorial service, Richard Farson eulogized him as ‘a quiet revolutionary.’

6.07.2.3 Humanistic Approaches: The Rise of Gestalt Therapy

Gestalt psychotherapy took root as a counter-response to the negativism of psychoanalysis. It was a logical extension of the movement toward personal direction and freedom that characterized Logotherapy and client-centered therapy. It did so, however, without relying on the abstract concepts of spirituality of these former approaches. Although the emergence of Gestalt therapy is generally thought to have been in the postwar years of the 1940s, its genesis actually was some 20 years earlier.

Friedrich [Fritz] Perls [1893–1970] was born in Berlin [Patterson & Watkins, 1996]. He obtained an M.D. degree from the Frederich Wilhelm University in 1920. Following his medical training, Perls worked under the direction of Professor Kurt Goldstein at the Frankfurt Neurological Institute for Brain-Damaged Soldiers. With the advent of WWII, Perls took his family to South Africa and in 1935, he established the South African Institute for Psychoanalysis. In 1946, he emmigrated to the US having become disillusioned with the arise of apartheid in South Africa.

By training, Perls was a psychoanalyst, but he was heatedly dissatisfied with the dogma and structure of psychoanalysis. He was also influenced by the experimental work of Kohler, Wertheimer, and Lewin, with whose work he gained familiarity during his early years in Germany. Other existential philosophers with whose work he also became familiar also eventually affected his work, but initially he was too preoccupied with orthodox psychoanalysis to assimilate their work [Perls, 1947]. Perhaps this is why he came to identify more closely with psychology than with psychiatry.

Fritz Perls met Laura Posner in 1926 while she was working on her Ph.D. in psychology. She was to become his wife and cofounder of Gestalt therapy. Laura Posner Perls' family was very affluent and culturally enriched, while Fritz was from a lower middle-class Jewish family. These class distinctions were to influence their relationship for many years.

Laura Posner Perls was heavily influenced by Martin Buber and Paul Tillich who were prominent contemporary existentialists. Laura and Fritz Perls worked closely together for nearly 25 years until they separated in the 1950s. Fritz Perls wrote his first book Ego, hunger and aggression subtitled “A Revision of Freud's theory and Method” in 1941 and 1942 while serving as a captain in the South African Medical Corps. Although it was not for many years that the name and character of “Gestalt therapy” was succinctly expressed, this first book introduced many of the Gestalt concepts which would later become central ideas in Gestalt therapy.

During the years that Fritz and Laura Posner Perls were together, Gestalt therapy was developing and maturing, although the particular contributions of Laura Perls often are obscured in the available writings. Although Gestalt therapy was first introduced in the US by Fritz and Laura Perls, it was not until Fritz found a home at Esalen Institute at Big Sur, California, in the 1970s that Gestalt therapy was recognized nominally as an independent theory. It was Fritz, not Laura, who came to be recognized as the discoverer, the father, and developer of Gestalt therapy. His estranged wife, Laura Perls, was residing in New York City, outside the mainstream of the human potential movement which was beginning in California. She published few papers, and her contributions to the theory and methods of Gestalt work were known only to a handful of people [Corsini & Wedding, 1989].

Those familiar with the work of Laura, and Fritz Perls note interesting differences in how they implemented Gestalt therapy. One of the most noted of these differences pertained to the dimension of control and permissiveness that they applied in treatment. Laura employed procedures that were characterized by apparent permissiveness, while Fritz's work emphasized therapist authority and control [Hatcher & Himmelstein, 1976].

The 1930s and 1940s were a dynamic time for Fritz Perls. He was heavily influenced by a number of prominent people including Wilheim Reich, who was Perls' analyst in the 1930s, Karen Horney, and Otto Rank. Horney was said to have directed the young and rebellious Perls to a very eccentric and rebellious Reich. Most notable in his influence was Reich, who introduced Perls to a theory of psychosomatic medicine that considered physical movement and symptoms as the body's armor against threat [Perls, 1947]. The body work and physical techniques of Gestalt therapy was a product of this earlier association.

However, it was Freud's theory of psychoanalysis that provided Perls with a theoretical framework for all of his future thinking; despite their differences, psychoanalytic theory was the major foundation upon which Perls built his understanding of human behavior, and it was psychoanalytic theory that he used as a standard against which to evaluate his own emerging theory. In Fritz Perls' autobiography, In and out of the garbage pail [Perls, 1969], he makes the following comment on Freud, “Rest in peace, Freud, you stubborn saint-devil-genius,” reflecting his own ambivalent attitude toward both Freud and psychoanalysis.

Gestalt therapy differs from other systems and models in a number of important ways. For example, Perls accepted psychoanalysis as a general theory from which his own view derived. However, he chose to omit certain aspects of Freud's theory from his own view, such as psychosexuality, the tripartite anatomy of the personality [id, ego, and superego], and the nature of the unconscious. As applied to technique, these omissions led Perls to emphasize how rather than why, and explored experience within the “here and the now” rather than the “there and then.”

Another difference is in the value assigned to various bodies of scientific research. Gestalt therapy draws from a broader scientific literature than most systems of psychotherapy. It placed greatest value on research that describes the nature of perception and information processing, as well as from literature on defense and psychopathology. At the same time, traditionally it has eschewed psychotherapy outcome research. This priority of values contrasts with client-centered therapy, for example, that has always valued outcome research, but has given little acknowledgment to research on psychopathology and personality development.

Still another distinguishing aspect of Gestalt therapy is its adoption of a holistic view of behavior. It regards individuals as being inherently integrated; their behavior reflects an integrated system whose collective activity cannot be understood by simply viewing isolated acts or structures. This humanistic view is borrowed from Rank, whose concept of the “total organism” contrasts with the psychoanalytic view that separated mind and body and divided the psyche into discrete elements, for example, id, ego, superego, that engaged in a struggle for power over one another. Instead, Gestalt theory asserts that people struggle and experience conflict because of the difficulty of incorporating new information into perceptions based on old knowledge.

Finally, Gestalt therapy defined self-actualization in a manner that contrasted with other experiential approaches. Self-actualization was reflected in balance, differentiation, and integration of cognitive, sensory, and emotional systems, rather than a motive toward social goodness. The ability of conceptual systems to communicate was manifest in the concept of self-response-ability, that is, the ability to choose to be active and to overcome apathy. Rather than encouraging social compliance, as might psychoanalytic therapy, Gestalt therapy encourages social rebellion and individualism.

Neutrality and a Nonjudgmental Attitude

Mosey identified empathy, compassion, and unconditional positive regard as some of the qualities or characteristics that facilitate therapeutic use of self by the therapist.63 We have discussed empathy and examined its role in the development of a therapeutic relationship consisting of mutual trust. Compassion refers to profound sympathy for another person's suffering and a desire to alleviate it. Unconditional positive regard refers to acceptance of another person as he or she is, as a valuable and dignified individual, irrespective of disagreement with the person's perspective and behavior. All the above characteristics seem to be part of the emerging theme of the need to be neutral, nonjudgmental, and curious about the client's experiences in helping disciplines.31 This theme implies the idea of “therapist as open to the meaning and the sense of the struggle in which” [p. 16]31 the client is engaged. The perspective of the theme, more specifically, is that “Used carefully and well, curiosity and not-knowingness should promote empathic connection with clients through demonstration of the therapist's desire to understand the client's experience” [p. 16].31

As mentioned earlier, it is also evident that the themes of empathy, neutrality, and nonjudgmental attitude, as is the case with most of the other themes of the therapeutic relationship, are derived from Rogerian client-centered therapy, which is defined as

a process of carefully listening to the client, accepting the client for who he or she is—no matter how confused or antisocial that might be at the moment—and skillfully reflecting back the client's feelings. The acceptance and reflection of feelings would create a level of safety for deeper exploration and a mirror in which to further understand and reflect on the client's own experience, which would lead the individual to further insight and positive action [p. 118].52

This characteristic is also a necessary part of a collaborative relationship.

Therapist skills that aid partnership: the core conditions

At the heart of patient-centred care is a whole-hearted or unconditional respect for the person, including valuing of his or her unique experiences, goals, resources and needs. According to Carl Rogers [1967], a pioneer of client-centred therapy, therapists who offer three ‘core conditions' are more likely to form a therapeutic alliance with their patients / clients. These are:

Warmth and unconditional positive regard

Genuineness

Empathy.

The core conditions have been variously interpreted as therapist personality traits or dispositions, attitudes or communication strategies. Burnard argues that:

These personal qualities cannot be described as ‘skills' but they are necessary if we are to use interpersonal skills effectively and caringly. They form the basis and bedrock of all effective human relationships [Burnard 1996 p. 45].

Unconditional positive regard or acceptance is respect that is given to the client / patient freely, ‘without strings'. Rogers referred to this as ‘prizing’ the person, regardless of his / her particular interests, problems, skill, beliefs and so on. According to Rogers' theoretical perspective, the experience of receiving unconditional acceptance releases the person from feeling obliged to seek approval and the goals imposed by other people, and helps the person to identify personally meaningful goals. Such experiences may be especially liberating for disabled people. Many comment on the strong social obligation to ‘pass' as ‘normal’ or to spend far too much time and energy on being ‘independent', when accepting assistance on mundane tasks would in fact improve quality of life and release energy for more interesting occupations. However, not all therapists offer patients unconditional respect. There is evidence that patients all too often feel depersonalised and devalued within the medical and rehabilitation system [Peloquin 1993].

The second core condition of genuineness requires the therapist to come out from behind the professional façade. It involves relating to patients as people. One example of such genuineness is given in MacLeod [1993], from her observational study of nurses relating to patients in a ward setting. She quotes from her field notes, about an interaction between a female patient and nurse in which the patient discloses her worry that her husband, left to his own devices at home, is boiling the laundry by mistake:

As she gives the suppository [to the patient] Sister Hanna listens and shares a story of when she was in hospital having her youngest baby and her husband boiled the jeans, long before boiled jeans were in style [MacLeod 1993 p. 186].

MacLeod goes on to note:

This excerpt speaks of how the ward sisters are present with patients, acknowledging and preserving their sense of being with persons as well as patients. The ward sisters touch their patients' experiences, by the timing and pacing of their actions, by listening and by sharing themselves and their own experiences [p. 186-7].

Genuineness is generally regarded as a challenging task, as therapists need to avoid imposing any of their own negative feelings on patients. For example, they should be careful about burdening the patient with their own reactions such as sadness, or irritability.

Thirdly, Rogers argued that client-centred therapy depends upon the therapist's willingness and ability to offer empathy. It may help to clarify the meaning of empathy by saying what it is not. It is not sympathy, which involves imposing one's own feelings of pity or sadness on to the person who is ill. Sympathy can appear over-sentimental and burdensome, leaving patients with a desire to protect the health professional from emotional distress. It can also be patronising to disabled people. Many reject having a ‘tragic’ status imposed upon them [Oliver 1998]. For example, an unthinking description of people as ‘victims' of diseases such as multiple sclerosis, or as ‘confined’ to a wheelchair, might be intended to convey sympathy but the terms are understood by some disabled people as demeaning and disparaging [Morris 1991].

Empathy involves placing oneself in the client's shoes, trying to understand – however imperfectly – how the client may be experiencing illness or impairment in the broad context of his / her life, family, work, and so on. It requires a willingness to suspend one's own judgements and assumptions about how the patient ‘must’ be feeling, and to listen carefully to all of the verbal and nonverbal information that the patient provides. It involves recognition that illness and pain have different meanings for each individual. Empathy sometimes involves a leap of imagination in order to glimpse how the world may look from the other's perspective. It is a far from passive process. As well as achieving an intellectual understanding, empathy involves sensitivity to one's own and the patient's feelings. Furthermore, it also involves communicating one's emerging understanding back to the patient, to invite correction of any errors, and to foster a genuine partnership. This process helps the client to acquire insights, and to feel heard [Maguire & Pitceathly 2002]. The patient is likely to gain greater clarity about his or her personal needs and goals as a result.

Respect and empathy may be thought of as personal attitudes on the part of the therapist, but they also need to be communicated by the therapist and experienced by the patient. Respect and empathy will not be of much help to the patient unless they are clearly expressed by the therapist through verbal and nonverbal behaviour.

As well as demonstrating the ‘core conditions', therapists use a wide repertoire of communication skills. These can be classified in many ways. For example, we may focus on verbal [word-based] ways of sharing information, and the nonverbal. Nonverbal cues include use of facial expression, eye contact, gestures, posture, orientation and distance between the partners, and paralinguistic voice qualities including tone, and emphasis. Nonverbal communication appears more prone to the unconscious leakage of emotions and attitudes, as people generally have less awareness and control over these behaviours. Communication skills have also been divided into task-oriented and socioemotional skills [Adams et al 1994, Klaber Moffat & Richardson 1997], and into sending [initiating] and receiving [responding] skills [Johnson & Johnson 2002]. The appropriate phrasing of questions can be presented as an initiating skill, whereas active listening and empathy may be classified as responding skills. However, such a binary classification soon breaks down when we realise that sensitive questions [an initiating skill] may in effect be a profound response to information just disclosed by the patient. Also, active listening skills [receptive skills] may be used quite deliberately by the therapist to help the patient to initiate further disclosure and to encourage the patient's confidence and trust in the relationship.

As a first step to partnership, therapists need to communicate a deep respect for patients. This is partly accomplished through basic courtesies, for example, using the patient's preferred style of address; asking patients'permission before touching them; preserving the patient's dignity, for example when undressed; protecting privacy by not having sensitive discussions behind flimsy ward curtains.

Furthermore, respect is associated with acknowledgement of the patient's unique lifeworld. The therapist attempts to empathise with the patient, rather than following a pre-set, ‘expert-led’ agenda. Not all health professionals manage to do this, as the following activity explores.

ACTIVITY Analysing therapist-patient interaction

In an earlier activity, you considered how a patient might cope more effectively in the aftermath of stroke if given appropriate information. The extract appears again below.

Examine the interaction between Martin [M] and his therapist [T], and note how each person is following somewhat separate agendas.

Why do you think such misalignments in the agendas of patient and therapist occur?

How might the therapist have responded to build more of a partnership or alliance with the patient? Suggest one or two verbal responses.

Formulate a brief response that offers more empathy, showing the patient that you realise that he is anxious about returning to his post as Head of Drama.

Martin is 55 years old and Head of Drama at a local secondary school. He suffered a stroke six weeks ago, and is making what his GP referred to as a ‘good recovery'. However, Martin has not yet returned to work, and continues to have some problems with weakness on his right side, and some dysarthria [problems in co-ordinating the muscles involved in speech]. His therapists note that he seems irritable and impatient during therapy sessions.

Barry et al [2001 p. 495] gave the example of a physician and male patient following separate agendas in a consultation [an extract of an interaction sequence from this study was given in Chapter 4]. In the research, the physician's reluctance to risk peering into the patient's lifeworld may have been associated with a view that the condition was simply ‘routine’ and manageable by medication. More fundamentally, the physician may have assumed that illness simply has a ‘biological reality', and that its social and personal aspects are irrelevant to treatment [Mattingly 1988]. Time pressures may also have restricted the clinician's focus to the biomedical aspects of the patient's condition. However, this response could readily suggest to the patient that his view was not relevant or wanted. Matthews et al [1993] point out that an empathic acknowledgement of the patient's fears and other feelings does not necessarily take much time. We need to acknowledge that the period available for consultation with patients is relatively brief. Yet it takes only a little time to respond in a caring way to a patient who has just described a health crisis or disclosed fears about the future. For example: ‘That sounds like a frightening experience. Perhaps it will help if we look at …', or ‘You seem very worried about…. Is there something you would really like to work on during therapy that would help you deal with these worries?’ Even the briefest acknowledgement is better than none, and helps to build partnerships. However, Barry et al [2001 p. 497] note from their observations that health professionals often regard the patient's life experiences and perspectives as relevant only to consultations about psychological matters.

More positively, Crepeau [1991] presented a case example of an occupational therapist who made a successful attempt to enter the lifeworld of a male patient who had received a spinal injury. Crepeau argued that for therapy to be successful, the agendas [or schemata] of therapist and patient need to be brought together. This can be achieved in part by the therapist's willingness to accept and understand the patient's perspective. For example, an effort needs to be made to understand how this particular patient is experiencing his physical dysfunction. The therapist also has the responsibility for educating the patient about the knowledge and skills that she / he is bringing to the therapeutic process. Crepeau analysed several interactions between a therapist and a patient, who had a hand dysfunction. She showed how much information about the patient's hand function was being exchanged in both directions during the encounter. This helped to draw the pair together in a mutual problem-solving alliance. The analysis also focused upon the power dynamics involved in the interaction between therapist and patient, and how the successful partnership depended upon the therapist's willingness to share power in the situation. For example, she asked open questions, showed interest in the patient's account of his injury, and responded sensitively when the patient showed that he had become unwilling to pursue the topic of sexuality. On a lighter side, some teasing and joking within the interaction signified a strong and growing partnership between the pair.

For a therapist to foster a partnership approach, sensitivity is needed in regard to the psychosocial aspects of illness / injury, as well as preparedness to negotiate mutually agreeable goals and treatment strategies. Therapists need skills to help patients voice their own agendas, for example through using open questions and invitations. Some disabled people are all too aware of being given few choices during social encounters. For example, Stack [1999 p. 32] describes her own experience using a wheelchair:

I have to stay firm in the knowledge of who I am and not be deflected by the constant barrage of other people's miscommunications … ‘I will put you over there …’ [not where would you like to be?].

Rebeiro [2000] found echoes of this complaint in an interview study of patients with mental health problems, looking at their experiences of occupational therapy services. The clients reported that they had received prescriptive treatment rather than a meaningful choice of activity. The social distance between therapists and clients made collaborative partnerships difficult to achieve. However, while this is an intriguing study, the findings are based on only two clients' viewpoints. Talvitie [2000] carried out a more substantial observational study of thirteen patient-physiotherapist interactions. Videotapes revealed that the physiotherapists sometimes ignored the patient's perspective by giving instructions during practice of skills, when patients really needed to concentrate fully on maintaining their balance. However, the therapists showed more patient-centred skills when they provided appropriate encouragement for patients who felt despondent about their progress. This study was valuable in showing that therapists use many different communication skills during the course of treating patients, being patient-centred in some respects but less so in others.

Other research confirms that patients all too often lack influence during interactions with health professionals. For example, Barry et al [2000] discovered that patients often leave their consultations with physicians with unvoiced agenda items. Part of the communication failure may result from adjunctive or contextual factors such as time pressures. Patients' common beliefs that health professionals will not want to be bothered by ‘too many’ health issues or personal problems may also prevent full sharing. Nevertheless, therapists themselves can block expression of psychosocial issues and impede joint decision-making about goals and treatments by failing to show listening skills, by leaving no thoughtful silences in the encounter, by asking many closed questions [which encourage patients to confine themselves to brief yes / no responses] and by tightly controlling the agenda.

There are a variety of useful questions that help to elicit patients' concerns, together with their expectations about the therapy and the therapist's role. Platt et al [2001] give many examples, including:

‘What sort of troubles are bothering you? … Tell me more about X, Y and Z.’

‘Tell me a little about yourself as a person … your work, who's at home, what goes on in your life?’

‘What are you hoping for?'

‘From what you have said, I imagine that this illness is very hard for you. Can you tell me what it's been like for you?’

‘My role is X and I can see that you're hoping for Y, how best can we proceed?’

ACTIVITY Formulating questions that invite partnership

The above suggestions help you to think about the use of open questions and the open invitation ‘Tell me about …'.

Formulate some further questions that would help a therapist to gain insights into patients' views of their illnesses, and their treatment goals, and that would therefore encourage a collaborative approach to therapy.

If any of the above questions seem a little unsuited to your own way of communicating, find another way of phrasing them so that they would fit in better with your own personal style, while still serving the same purpose.

If possible, swap the questions that you have formulated with someone else, and evaluate how effective they might be.

Therapists who wish to gain the patient's involvement in therapy as a joint venture may find it helpful to explore the use of assessment tools that are designed to encourage the patient to participate in goal-setting and treatment planning. Some occupational therapists, for example, use the Canadian Occupational Performance Measure [COPM], as it is designed to increase partnership-working [Wressle et al 2002]. Goal attainment scaling provides another means by which therapists and patients can collaborate on setting goals and evaluating progress towards goals. Fisher and Hardie [2002] evaluated the effectiveness of goal attainment scaling in a multi-disciplinary pain management programme. They explained that this approach asks patients to identify which problems they wish to work on, and to plan specific, personally meaningful goals in relation to each problem area. The goals are very explicitly formulated. The researchers give the example of a patient deciding to work on a newsletter in the next six months, and setting a goal of ten pages of information. If the goal is achieved, the patient will score 0. If more is accomplished than the plan envisages, then the patient will score +1 or +2. Similarly, if less is accomplished than stated in the goal, the patient scores -1 [or -2 if the patient achieves less than the point at which treatment started]. Fisher and Hardie [2002] report that the patients achieved significant improvements in mobility and activity. It would appear that such an approach to therapy encourages an alliance to form between therapist and patient, and that it harnesses the patient's motivation.

While therapists can do much to negotiate a shared agenda in their encounters with patients, partnership working is nevertheless constrained by numerous adjuncts to the therapist-patient dyad. For example, in settings where there are enormous time pressures, and limited co-operation among therapists and other health professionals in the wider team, it is much harder for effective partnerships to form at the therapist-patient level. We will return to these issues later.