Are You Treating the 'Whole' Patient?

If you are a practitioner, or are studying to become one, you will likely spend countless hours exploring the concepts of activity analysis (1), purposeful activity, treatment strategies and various methods of assessment. However, definitions of occupational therapy often state that we work with the 'whole' patient. In our current medical environment, with its emphasis on productivity, do we actually take the time to treat the 'whole patient'?

As I pass through the 38th year of my career as an occupational therapist (OT), it is a question that I frequently ask myself. I entered our field as a 'non-traditional' student - having spent four years in the military, followed by six more as a school counsellor, before discovering the field, quite by accident one day.

Why do I see working with the 'whole patient' as being so very important in delivering quality occupational therapy?

Clients don't suddenly wake up one day thinking "Gee, I think I’ll go see an OT." They are sent to us - usually not of their own choice. They are often in pain and frightened of the long term consequences of an injury, condition, or state in the ageing process. Most would rather be anywhere other than sitting in with us. 

In the years I spent as an associate professor, I always advised my students to be conscious of the following:

In those first few minutes of contact, TWO assessments are taking place. You are assessing the diagnosis and its impact on your client's activities of daily living (ADLs). But they are also assessing you. 

Do you seem interested in them as a person, or do you come across as in a hurry to finish with them and get onto the next patient? Do they feel they can trust you - both in terms of your skills, as well as concern for them?

In truth, not all of this flows from altruism on my part. One of the issues we frequently have with clients is engagement with the home program we provide them. I want my clients to understand that, for each 45-60 minute session I spend with them, they are the most important person in the room. It's this involvement that supports with their attendance to their care plan and recovery.

Occupational Therapy is a collaborative approach, which supports with engagement in goals and recovery through purposeful activity.

Plus, in all honesty, I want them to feel a bit guilty if they are not doing that home program. Sneaky yes, but I’ve found that it works!

Developing a therapeutic relationship (2) has always been important to me, but building rapport is just as important. The process of developing that rapport does not even have to be intentional; it should be a part of who you are, how you treat anyone who walks through the doors of your clinic. 

One of the faculty in our program was an older psychiatric occupational therapist, who came to us from the UK. Her name was Patricia O'Kane, so we assumed she was Irish. Most of her career had likely been in the 1950s-60s, based on her stories of work in various psychiatric hospitals. She had been 'classically trained', meaning that she proceeded from a psychoanalytic framework. She related a story that has stayed with me across the years (even though I primarily work in physical disabilities)...

Early in her career she worked in locked wards and she would remove the ring of keys that staff wore around their neck to enter a ward. Almost immediately, when entering one women's ward, she would encounter a naked patient, who lay with her head and most of her torso under a cast iron heater. We will call the woman 'Gloria'. She would always greet the patient with a "Good morning Gloria!" Gloria never replied, or acknowledged this greeting.

Months passed, the first psychotherapeutic medications (likely lithium), began to appear in these hospitals. A short number of days later, a young woman entered Patricia's office fully clothed and neatly groomed. To Pat’s surprise, the young woman addressed her, stating:

"Ms O’Kane, my name is Gloria and I wanted you to know that the greeting and sight of your ankles every morning for the past year was what helped me maintain some semblance of sanity."

Now this is what I mean by unintentionally building rapport. Gloria was not one of Dr. O'Kane's patients. Rather, out of her own caring, Patricia had reached out to this woman, on a daily basis.

As an occupational therapist, I want to establish some medium of rapport with any patient or family member I meet in the hospital. I will make a special effort to help my clients feel comfortable and valued when working with me. But I also want that effort to extend to the elderly gentleman I run into in the hallway if he appears lost.

What do you know of your patient's lives? 

What have they experienced so far? 

Gaining the trust of your clients will further your education. I assure you of that. 

A few examples of how rapport-building and earning clients' trust can do this:

• My African-American clients have revealed to me what it was like to grow up here in the American South in the 'old days'.

• A Puerto Rican client told me of the history of indigenous people in his former country.

• An older woman - approaching the end of her life - told me that she had absolutely no interest in her own ADLs, as she knew she was dying. I asked her what she might want to do instead. She agreed to trade a bit of her remaining time doing ADLs, if I were willing to listen to her reminisce about her life as a concert pianist, performing all over the world.

• A World War Two (WWII) aviator, described initially as the 'laziest man you will ever meet', told me of his experiences in the Pacific in WWII. He shared how he came to decide that he would spend the remainder of his life flying in and out of remote locations in South America, bringing dentistry and religion to the inhabitants he met.

I believe that occupational therapy can be one of the most fascinating occupations possible.

After nearly four decades in the field, I continue to be fascinated by the stories of patients who 'walk' beside me for a time, as we work together to maximise their ability to perform ADLs and IADLs. I understand that productivity is what 'keeps the doors open', in the facilities in which I have worked. But for the 45 minutes I work with a client, it is the client who is the most important entity in the world for me.

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Think of a new client being like this image of a frozen puddle; much of it cloaked from your view... As you build rapport, hidden parts gradually come into view. In the end, you visualise the whole patient.

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Further Reading and Resources

Occupational Therapy - Activity Analysis

Buy Now

1. The Occupational Therapy Hub (2024) Occupational Therapy - Activity Analysis. In 'Hub Store', on The Occupational Therapy Hub (online). Available from: https://www.theothub.com/product-page/occupational-therapy-activity-analysis.
   

2. Abson, D. (2019) Therapeutic Use of Self. In 'Therapy Articles', on The Occupational Therapy Hub (online). Available from: https://www.theothub.com/article/therapeutic-use-of-self.
   

3. The OT Practice (2019) Mental and Physical Health: Why they go hand in hand. In 'Therapy Articles', on The Occupational Therapy Hub (online). Available from: https://www.theothub.com/article/mental-and-physical-health-why-they-go-hand-in-hand.