Sustaining the “Self” in Therapeutic Use of Self

Annemarie Connor, PhD, OTR/L; Sarah Fabrizi, PhD, OTR/L; Lauryn Combs, OTS; Aubrie Fry, OTS

In the ever-evolving profession of occupational therapy, practitioners are often inundated with new technologies, standardized assessments, and specialized protocols. While these are essential, we must not overlook the most foundational instrument in our clinical toolbox: therapeutic use of self. Broadly conceptualized as the working alliance (WA), this is a collaborative relationship defined by agreement on goals, consensus on tasks, and strong interpersonal bonds (Bordin, 1979). This article operationalizes the WA as an evidence-based practice foundational to effective intervention and a critical protective factor against therapist burnout.

The Alliance as Level I Evidence

The WA is not a "soft skill"; it is a Level 1 evidence-based predictor of clinical success. Meta-analytic research demonstrates that the strength of the alliance reliably predicts outcomes across theoretical approaches, often influencing results as much as specific techniques (Flückiger et al., 2020).

Recent research underscores its impact across diverse settings:

• Physical Rehab: In stroke recovery, the quality of the WA shapes engagement and goal setting (Bishop et al., 2021). Similarly, stronger alliances in settings addressing chronic pain management correlate with improved functional outcomes (Kinney et al., 2020).
• Vocational Rehab: Higher alliance ratings predict longer work tenure for individuals in supported employment (de Jong et al., 2021).
• Telehealth: "Therapeutic presence" can be maintained digitally when therapists intentionally adapt empathic communication, such as increasing explicit verbal reflections to compensate for limited nonverbal cues (Hall et al., 2022).

Bridging the Training Gap

Despite its empirical weight, the WA is frequently underexamined in education. While students acquire discrete "microskills," they often struggle with the cognitively complex skills required for genuine therapeutic attachment and holistic case conceptualization (Connor & Leahy, 2016). Building a WA requires mastery of the affective domain, specifically empathy, congruence, and unconditional positive regard (Rogers, 1951). Because these skills are not easily acquired through didactic learning alone, there is an ethical imperative for practitioners to engage in continuous self-reflection and intentional relationship building to ensure professional competence and efficacy (Connor & Leahy, 2016; Stige, et al., 2024).

Operationalizing the Alliance: GUE and OARSS

To translate these concepts into practice, therapists can utilize the "core conditions" of the therapeutic relationship (Rogers, 1951), remembered by the acronym GUE (Connor, 2025):

• Genuineness (Congruence): Being an authentic human presence.
• Unconditional Positive Regard: Creating a non-judgmental space.
• Empathy: Ensuring the client feels deeply understood.

These conditions are operationalized through the Empathic Listening Sequence, remembered by the acronym OARSS (Connor, 2025):

1. Open-ended questions: Inviting the client to share their narrative before moving to structured assessments or interventions.
2. Affirmations: Recognizing client strengths and efforts.
3. Reflections: Rephrasing the client’s emotional or factual content to demonstrate active understanding. Mirroring mood/tone.
4. Summary statements: Synthesizing the client’s story to ensure alignment on goals.
5. Silent pause: Providing the necessary space for processing.

By using these techniques during the initial encounter and evaluation, therapists can ensure that the essence of the client's story is captured (Connor, 2025).

The Alliance as a Shield Against Burnout

One compelling argument for prioritizing therapeutic use of self is its dual role: while it enhances client outcomes, it simultaneously serves as a protective factor for the clinician. Burnout is characterized by emotional exhaustion, cynicism, and a reduced sense of personal accomplishment, and is a significant risk in our client-centered profession (Shin et al., 2022). The intentionality required by frameworks like the Intentional Relationship Model (IRM; Taylor, 2020) encourages OTs to utilize their personality through a lens of self-awareness. Recent research (2021–2024) suggests that clinicians who master the alliance report higher professional fulfillment and lower rates of moral injury, as the depth of the therapeutic connection provides a sense of purpose that buffers against systemic workplace stressors (Duncan et al., 2024).   Furthermore, creating a self-compassionate stance toward one’s own clinical performance appears to be a practical buffer against burnout. In a randomized trial with healthcare professionals, a brief online self-compassion intervention reduced stress and burnout outcomes (Super et al., 2024).

Practical Strategies for Clinical Practice

• Intentional Goal Alignment: Ensure the client is the primary author of their goals.
• The "Check-In": Periodically ask, "Do you feel we are focusing on the things that matter most to you?"
• Active Curiosity: Adopt a stance of deep curiosity regarding the client’s narrative so that trust is fostered and compassion is cultivated.
• Model Self-Compassion: Recognize that your own self-regulation is an essential clinical task.

Conclusion

Occupational therapy has long relied on therapeutic use of self, yet it often functions as an unexamined instinct rather than an intentional clinical tool. Failing to deliberately cultivate the WA risks underestimating one of our most powerful mechanisms of change. The clinical toolbox is filled with essential protocols and interventions, but without GUE and OARSS, a vital factor is missing. These skills transform routine interactions into collaborative partnerships, ensuring intervention is co-created in alignment with what truly matters to the client.

Simultaneously, the alliance sustains the clinician. Intentional therapeutic presence reconnects practice to purpose, acting as a buffer against burnout and restoring meaning within demanding systems of care. The WA is both empirically supported and profoundly human. When deliberately nurtured, it is not simply a skill to add to a practitioner's repertoire; it remains one of the profession’s defining strengths, i.e., a bridge between evidence and lived experience that allows occupational therapy to achieve its greatest impact.

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