INTRODUCTION
In acute psychiatric settings, the therapeutic relationship is key to outcome (Bjørngaard et al. Reference Bjørngaard, Ruud and Friis2007). The Intentional Relationship Model (IRM) is an approach that focuses on aspects of the relationship that provide a basic foundation for all other approaches to care and rehabilitation. Additionally, it informs how the therapist manages inevitable tensions within the relationship. Using a case example, this paper will explain IRM as a means for mental health professionals to be more deliberate in their approach to all of their interactions, particularly those involving more challenging service users.
Taylor (2008) introduced the IRM to explain dynamics that occur during particularly tense or complicated interactions, and as a guide to allow professionals to learn how to maximize or attenuate certain aspects of their personalities so as to strengthen their relationships. The IRM emphasizes that the professional must be intentional in reading and understanding sources of tension and connection within the relationship, knowing each service user’s typical way of relating and reacting in therapy, and choosing which aspects of their personalities to reveal based on these understandings (i.e., what Taylor refers to as ‘therapist interpersonal modes’). According to the IRM, ‘modes’ are used to build a foundation of open communication, mutual respect, and trust.
Therapeutic ‘modes’ are the specific aspects of personality that a therapist uses when interacting intentionally with service users. Based on research (Taylor et al. Reference Taylor, Lee, Kielhofner and Ketkar2009), the IRM describes the following six modes as having therapeutic potential: instructing, encouraging, collaborating, problem solving, empathizing and advocating. Whilst all modes have equal potential to be effective during the therapeutic relationship, if a single mode is used too frequently, is not consistent with the service user’s personality, or does not meet his or her interpersonal needs at that moment, it can inhibit therapy progress (Taylor, Reference Taylor2008). Therapists who are aware of their own mode use can become more deliberate in interacting with service users by selecting the most appropriate modes for a given service user and by shifting to a different mode when it is clear that one is no longer effective. The following is a case study in which the use of modes informed by the IRM was crucial to the development and maintenance of an effective therapeutic relationship. The case study is a compilation of several case studies, identifying features have been changed to protect the identity of clients.
CASE STUDY
Benny
Benny is a 17-year-old service user with a spinal cord injury (level C8) and comorbid major depression. He was receiving care at an outpatient day rehabilitation setting. Benny had a history of alcohol abuse, impulsivity, risk-taking behaviour, poor judgment, and depression. In therapy, Benny was often silent, forcing his older brother to answer questions for him. It quickly became apparent to the therapeutic team that he was depressed and was going to be challenging to engage.
Following a psychiatry referral, Benny elected not to follow through on the psychiatrist’s recommendations for anti-depressant medication. Shortly thereafter, Benny began to refuse other rehabilitation activities. He would not bring required equipment to sessions and he failed to follow through with homework assignments. In response, many of the therapists on the unit repeatedly attempted to offer Benny a choice in activities. Additionally, some would religiously seek his opinion on the way he thought certain actions should be performed. Benny would refuse to choose and on more than one occasion stated sarcastically ‘you guys are the experts’ when asked his opinion.
The first author (CS), a new graduate trained according to the Intentional Relationship Model, soon became involved in Benny’s treatment. From observing her colleagues’ difficulties with Benny, CS learned that attempting to empower him by providing choice (collaborating mode) and quizzing him about how to perform certain activities (instructing mode) were not modes that were going to work straightaway. Instead, CS attempted to engage him in casual conversation and encourage him whenever he showed an interest in activities (encouraging mode). This more relaxed approach, coupled with subtle efforts to reinforce and praise him for his interests (encouraging mode), did not produce any resistance, so CS soon discovered at least one IRM mode that seemed to work with Benny.
CS received additional reinforcement for her choice to use the encouraging mode by observing interactions between Benny and his brother. Benny’s brother seemed to be the only person who could relate to him successfully, and this was through teasing and joking. Accordingly, CS started to use humor with Benny in a respectful yet spontaneous way (encouraging mode). For example, Benny knew she was a new therapist and would often mock her whenever she had difficulty adjusting his equipment or chair. He would shake his head and sigh, stating, ‘Ohhh, Caitlin’. Despite the teasing, CS freely laughed at herself in response. Subsequently, when Benny refused to work on his computer access skills during the next session, CS decided to tease him in return, shaking her head and stating ‘Ohhh, Benny’. Both laughed and, from then on, this ‘mockery routine’ became a shared source of connection between them.
This encouraging mode of interaction provided the first author with an avenue for acknowledging the moments of resistance in therapy, and eventually it allowed Benny to feel more comfortable expressing himself and making choices about which activities he did and did not prefer (collaborating mode). Thus, the encouraging mode provided CS with entrée to use the collaborating mode – a mode that Benny had resisted when other therapists attempted to probe his interests and provide choice.
One of the most memorable sessions with Benny involved working on self feeding. For the first time, Benny was invested in an activity and was experiencing a fair degree of success with it. Suddenly, Benny’s mood changed from one of excitement and pleasure to one of despondency and withdrawal. When CS asked him gently what he was feeling or if she had said something wrong (empathizing mode), he responded by asking her if she would like to ‘eat like this’ if she were in his position (he was using a universal cuff to scoop popcorn from a bowl). CS responded in stunned silence and then made a very honest admission about how she would not like to feel like she stood out or looked differently from other people (empathizing mode). After that session, their relationship grew even stronger.
This empathy and bonding became important, since Benny’s depression was deepening. He began to refuse to catheterize himself or allow anyone else to do it, which put him at risk for many serious physical reactions. More often, he stated that there was ‘no point’ to learning to do anything he once enjoyed. With gentle but precise inquiry (empathizing mode) this culminated in a disclosure of Benny’s intention to use the razor from his shaver to cut his carotid artery.
Benny was moved to a secure psychiatric unit within the hospital and was clearly angry with CS for interrupting his wish to die. CS acknowledged and validated his anger, and they soon resumed their ongoing discussions together. However, Benny remained very hostile with the staff on his psychiatric unit and was highly resistant to all treatments, including taking his medications. Many staff on the psychiatry unit responded to Benny’s challenging personality style by lecturing him and informing him of the consequences of his behaviours (instructing mode), encouraging him to weigh the pros and cons of his behaviours (problem-solving mode), or offering resources and access to support groups (advocating mode). These were not Benny’s preferred ways of interacting, and it is possible that he did not form any significant relationships on that unit as a result. Once stable on medication, Benny was ultimately discharged back to outpatient rehabilitation.
For weeks, Benny’s progress continued to vacillate. During his final session, however, CS noticed a distinct change. Benny wanted to work on signing his name (which had been an activity that he typically avoided). The reason for his sudden interest in this activity was revealed when he produced a farewell card for her. He informed CS that he wanted to sign it himself.
DISCUSSION
The case of Benny exemplifies how self-reflection and disciplined action through the use of interpersonal modes can significantly alter the course of even the most challenging therapeutic relationships. When service users exhibit difficult behaviours, many professionals rely upon tried and true approaches that typically work with most people (e.g. collaborating, advocating, instructing, and problem-solving modes). However, not all service users are alike, and often we forget that vulnerable individuals like Benny may require us to suspend use of our more authoritative modes until we have revealed ourselves as being humanely interested in understanding others and equally vulnerable. This can only be achieved by using empathizing and encouraging modes. By relying more heavily on the encouraging and empathetic modes, CS was able to gradually introduce her other modes and thereby establish progress toward treatment goals. IRM provides a theory base to be deliberate in the use of self with service users and provides a language for the discussion and reflection of these concepts. More information about the IRM may be found in Taylor (2008).
