The OT avatar: Redefining therapeutic use of self, post-pandemic

The COVID-19 pandemic put unprecedented strain on occupational therapy practitioners (OTPs), leading to high rates of clinician burnout. A survey completed before the pandemic found that many OTPs experienced burnout and feelings of emotional exhaustion several times per month, and felt a sense of depersonalization several times per year (Shin et al., 2022). It is reasonable to assume that the COVID-19 pandemic has increased these feelings of burnout, emotional exhaustion, and depersonalization. In fact, more than one third of rehabilitation therapists report feeling burnout driven by high caseloads and long work hours (WebPT, 2022).

Burnout results from “chronic workplace stress that has not been successfully managed. It is characterized by three dimensions: 1) feelings of energy depletion or exhaustion; 2) increased mental distance from one’s job or feelings of negativism or cynicism related to one's job; and 3) a sense of ineffectiveness and lack of accomplishment” (World Health Organization, 2019).

The pandemic has brought about multiple challenges for OTPs, including temporary re-deployment to other roles, using personal protective equipment (PPE), adapting to telehealth, and coping with staffing shortages. Many practitioners were overwhelmed by these challenges. An international survey of OTPs found that 65% of respondents felt unprepared to work during a pandemic, while 58% rated the services they provided as having a medium or low level of effectiveness (Hoel et al., 2021). Given these stressors, many OTPs have considered leaving direct care. In fact, within the United States, 8.8% of rehabilitation therapists resigned from their position in 2021, and two thirds are currently considering a career move (WebPT, 2022). All OTPs, regardless of practice setting, must recognize and address burnout in order to maintain a healthy and effective workforce.

The OT avatar

OTPs are driven by an intrinsic motivation to help others, which is fueled by the therapeutic relationship they build with their clients. Therapeutic use of self is the dynamic process by which OTPs develop and manage collaborative relationships with their clients to facilitate the therapeutic process by helping clients understand information, set goals, and develop hope for their future (Taylor & Van Puymbrouck, 2013). Two factors during the COVID-19 pandemic have changed how OTs use their therapeutic use of self: the first is shared trauma between therapists and clients, and the second is depersonalization of health care workers related to PPE use. Some OTPs report these factors have led them to feel like an “OT avatar,” the generic OTP who remains when personal factors are concealed.

The COVID-19 pandemic is unique in that it affected both practitioners and clients, creating a shared trauma. In the typical therapeutic relationship, the practitioner and client come together with different life experiences. Health care practitioners often experience secondary trauma through exposure to their clients' past traumas; however, the COVID-19 pandemic was a universal experience, creating trauma for practitioners and clients alike (Fink-Samnick, 2022). Yet OTPs are expected to be able to suppress intense emotions in order to maintain a professional façade.

The therapeutic relationship has been further complicated by PPE use, making health care professionals less intimate with the people they serve: people are hard to identify, and facial expressions are masked. High workloads and shorter lengths of stays have led to less direct and sustained client contact in favor of more case-management and triage type services, thus limiting time to establish therapeutic relationships (Brown & Pashniak, 2018). This furthers OTP feelings of depersonalization and burnout.

OTPs have the opportunity to assist clients in redefining roles and routines post-pandemic while addressing post-pandemic mental health concerns. To achieve this, they must develop strategies to combat burnout and be intentional in evolving their therapeutic use of self.

Strategies for success

In order to be effective practitioners, OTPs must first take care of themselves. OTPs should develop strategies not only for self-care, but for trauma-informed self-care (TISC). TISC is the practice of being aware of one’s response (emotional, behavioral, physiological) to clients who have experienced trauma, as well as having positive coping strategies and tools to manage one’s reactions (Miller et al., 2018). Tools may include regular exercise, sleep hygiene, mindfulness practices, or setting boundaries for work–life balance. It is essential to find restorative activities rather than distractions. Restorative activities engage the mind and body in a deep, coordinated way, as well as provide a sense of freedom, joy, and relief. Interestingly, reinforcing a professional identity through professional networks, seeking supervision, working within teams, participating in professional development activities, attending trauma and secondary trauma trainings, and engaging in occupation-based practice can be restorative activities (Ashby et al., 2013; Miller et al., 2018; Rivard & Brown, 2019). OT supervisors should intentionally hold regular individual and team meetings to foster professional engagement and provide TISC support (Ashby et al., 2013; Shin et al., 2022).

Pandemic-related trauma is unique in that it is shared by practitioners and clients alike, so the OTP must be self-aware in addressing their own needs while addressing the needs of their clients. Within establishing the “new normal” as a society, health care must also find its “new normal” by steering away unrealistic expectations for providers to push through tirelessly while disregarding themselves in the process. To do this, the health care system must support TISC for employees (Fink-Samnick, 2022).

The OTP should identify situations and topics that are associated with their own past traumas and have proactive plans to deal with these types of scenarios. This could include rehearsing verbal responses, or using sensory modulation strategies, relaxation exercises, or mindfulness techniques.

After the OTP has developed TISC practices, they will use their therapeutic use of self-more effectively. Therapeutic use of self includes self-reflection to understand one’s strengths, weaknesses, triggers, and traumas. It requires actively building skills to manage emotions, frustrations, triggers, trauma, and burnout while learning to use their individual personality and skills sets to build rapport, increase trust with clients, and reestablish the health care journey, which involves achieving goals and promoting quality of life for both OTPs and clients.

Because therapeutic relationships are more difficult to establish in the current health care environment, OTPs must be more intentional in the use of “getting to know you” activities when initiating care. This begins with careful attention to detail when completing the occupational profile, educating the client on OT’s unique role on the care team, and sharing personal information appropriately.

Communication is essential to building strong therapeutic relationships during both in-person and telehealth interactions. Nonverbal communication such as body language, hand gestures, physical contact, and affect were impacted by the pandemic due to telehealth and PPE. Often, nonverbal communication is unconsciously processed by clients to determine safety before processing verbal communication. When this is absent, it is essential for OTPs to be clear, concise, and direct with verbal communication. Although humor can often break the ice, when nonverbal communication is limited, clinicians must avoid smiling or laughing when firm or assertive messages are being delivered, as well as avoid slang and jargon. Incorporating reflective listening approaches such as paraphrasing, mirroring, limiting interruptions as the client is expressing themselves, limiting body language, and asking open-ended follow-up questions to ensure understanding can help build a strong rapport (Passmore, 2022). In the telehealth setting, providers should incorporate pauses into their communication to avoid interrupting the client during technology lags. The OTP will need to be intentional with their use of therapeutic modes throughout treatment. OTPs should validate client feelings, establish trust, do the work to not take client interactions personally, and assume advocacy roles.

Finally, it is important to remember that no one in health care is alone. There are many resources available for OTPs to develop professional networks. For some, informal support with coworkers is sufficient, whereas others may prefer activities provided by professional associations such as the CommunOT social site offered by the American Occupational Therapy Association. Many workplaces offer employee assistance programs for psychosocial support resources. Anyone in the Unites States considering suicide or other forms of self-harm should call the national Suicide and Crisis hotline at 988 for immediate assistance.

Case study

Kayla (not her real name) is an OT student who completed her fieldwork during the pandemic. Kayla struggled with applying course work that occurred in a virtual format to real-life fieldwork clients.

Kayla’s first Level I fieldwork experience was completed in a virtual context, which resulted in initial difficulty with building rapport and connecting with clients. Breaking the ice was challenging due to decreased ability to rely on things like humor or nonverbal communication.

With coaching from her fieldwork educator (FE), Kayla was able to achieve success by finding the “just right” amount of sharing of personal experiences, applying reflective listening, and integrating client interests into the process, even when these interests were not the primary focus, to build rapport and support client buy-in to treatment.

Kayla’s Level II experience was at an in-person acute behavioral health hospital. She reported feeling “shell shocked” by the extreme adjustment from virtual experiences to resuming in-person in both her personal and educational lives. The behavioral health hospital environment was busy, chaotic, and required working with a vast array of interdisciplinary team members. To provide needed care and services, Kayla needed to build rapport with a diverse client population. Kayla was overwhelmed and reported feelings of burnout, worthlessness, and hopelessness.

With close mentoring from her FE, Kayla had to learn about herself, and accept all parts of herself to build a trusting therapeutic relationship in a setting that was drastically different than her past learning environments. Kayla was successful because of intentional interactions with her FE that included role-play and self-reflection activities. These activities were accompanied by sharing and processing with her supervisor, peers, and other students across disciplines, Additionally, opportunities for direct-care cotreatment with other students encouraged peer support. Finally, Kayla was coached in habituating self-care into her workday through structured processing times, movement breaks, protected lunch time, and creating a shutdown routine for the end of the workday.

In summary, Kayla was successful because her FE’s incorporation of TISC into her fieldwork experiences.

Conclusion

Although the COVID-19 pandemic is over, the stress of health care remains. The lessons learned on the benefits of TISC should be carried forward to decrease the risk of health care worker burnout. TISC is an evolving practice, and as new challenges arise, OTPs must constantly reflect and update their response. It is expected that TISC strategies will change and grow over time to meet evolving demands on OTPs. Facilitating ongoing conversations about TISC is essential for OTPs to maintain a healthy and engaged workforce and ensure the sustainability of the profession.

References

Ashby, S. E., Ryan, S., Gray, M., & James, C. (2013). Factors that influence the professional resilience of occupational therapists in mental health practice. Australian Occupational Therapy Journal, 60, 110–119. https://doi.org/10.1111/1440-1630.12012

Brown, C. A., & Pashniak, L. M. (2018). Psychological health and occupational therapists: Burnout, engagement and work addiction. Work, 60, 513–525. https://doi.org/10.3233/WOR-182759

Fink-Samnick, E. (2022). Collective occupational trauma, health care quality, and trauma-informed leadership: Intersections and implications. Professional Case Management, 27(3), 107–123. https://doi.org/10.1097/NCM.0000000000000559

Hoel, V., von Zweck, C., Ledgerd, R., & World Federation of Occupational Therapists. (2021). The impact of Covid-19 for occupational therapy: Findings and recommendations of a global survey. World Federation of Occupational Therapists Bulletin, 77(2), 69–76. https://doi.org/10.1080/14473828.2020.1855044

Miller, J., Donohue-Dioh, J., Niu, C., & Shalash, N. (2018). Exploring the self-care practices of child welfare workers: A research brief. Children and Youth Services Review, 84, 137–142. https://doi.org/10.1016/j.childyouth.2017.11.024

Passmore, J. (2022). Motivational interviewing techniques: Reflective listening. In D. Tee & J. Passmore (Eds.), Coaching practiced (D. Tee & J. Passmore, Eds.). https://doi.org/10.1002/9781119835714.ch23

Rivard, A. M., & Brown, C. A. (2019). Moral distress and resilience in the occupational therapy workplace. Safety, 5(1), 10. https://doi.org/10.3390/safety5010010

Shin, J., McCarthy, M., Schmidt, C., Zellner, J., Ellerman, K., & Britton, M. (2022). Prevalence and predictors of burnout among occupational therapy practitioners in the United States. American Journal of Occupational Therapy, 76, 7604205080. https://doi.org/10.5014/ajot.2022.048108

Taylor, R. R., & Van Puymbrouck, L. (2013). Therapeutic use of self: Applying the Intentional Relationship Model in group therapy. In J. C. O’Brien & J. W. Solomon (Eds.), Occupational analysis and group process (pp. 36–52). Elsevier.

WebPT. (2022). The state of rehab therapy 2022. https://get.webpt.com/state-of-rehab-therapy-2022/

World Health Organization. (2019). QD85 burnout. In International statistical classification of diseases and related health problems (11th ed.). https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/129180281

Sara Kate Frye, OTD, MS, OTR/L, ATP is an Assistant Professor in the Institute for Occupational Therapy Education at Widener University in Chester, PA. In addition, she practices occupational therapy and supports professional development activities at Penn Medicine at Home. She can be reached at sfryeot@gmail.com.

Shawna Gigliotti, DrOT, OTR/L, is the Director of Training and Development for Belmont Behavioral Hospital System supporting system wide education and training initiatives for interdisciplinary staff, reducing usage of restrictive interventions for patients, and overseeing a team of occupational therapists and occupational therapy programming in the inpatient mental health hospital setting as well as outpatient and partial hospitalization services.