"Therapeutic Use of Self": The Concept of "Action and Reaction" in Dementia Care
By Kim Warchol, OTR/L
There is tremendous benefit to understanding a simple concept which is "action and reaction" as it relates to interacting with someone who has Alzheimer's disease or a related dementia (ADRD). This concept needs to be fully comprehended and acknowledged by all those who interact with those with ADRD in order to facilitate the best possible outcomes.
The concept implies that one person "acts" and the other responds with a "reaction." To explain this, below are simple examples from everyday life:
Person 1 – Smiles and says hello (initial behavior)
Person 2 – Smiles back and asks how your day is going. (action)
Person 1- Pulls up a chair and begins to visit. (reaction)
Person 1 – Walks in to the office kitchen area and takes something out of a refrigerator (initial behavior)
Person 2 – Coldly says, "Put that back. I wanted to drink that and it is the last one." (action)
Person 1 – Puts the item back in the refrigerator and walks away with frustration. (reaction)
Person 1 – Says, "I am so overwhelmed. I don't know how I am going to make it through this day."
Person 2 – Says nothing. (action)
Person 1 – No longer continues the discussion and leaves the room feeling unimportant. (reaction)
How one acts when a behavior occurs predicts the tone of the reaction and the direction of the interaction thereafter. We can shut someone down or open the person up. We can acknowledge someone or ignore the person. Our action to the behavior will drive the person's reaction.
Let's give a common interaction example from a nursing home environment involving a person with ADRD and a staff member.
Resident – Walks up to the nurses station and begins to explore some paper on the desk. (initial behavior)
Staff Member Action Possibility 1: "Millie, LEAVE that alone and go sit down!" (action)
Resident – The resident becomes angry, agitated, or sad and behaves accordingly. (reaction)
Staff Member Action Possibility 2: "Hi Millie. It is so nice to see you. How about you come sit with me and help me to fold these towels while I write my notes?" (action)
Resident – The resident feels noticed, important, and needed and happily engages in the activity. (reaction)
As the example above demonstrates, how we act when a behavior occurs is vital to what happens next. Therefore, do not underestimate the power of your "therapeutic use of self." The benefits of "therapeutic use of self" have long been described in our therapy profession.
Mosey states that conscious use of self is
"the use of oneself in such a way that one becomes an effective tool in the evaluation and intervention process" (Mosey, 1986, p. 199). It "involves a planned interaction with another person in order to alleviate fear or anxiety, provide reassurance, obtain necessary information, provide information, give advice, and assist the other individual to gain more appreciation of, more expression of, and more functional use of his or her latent inner resources." (Source: Mosey, A. (1986). Psychosocial components of occupational therapy. New Psychosocial components of occupational therapy. New York: Raven Press.)
Therefore, a therapist and others must begin to focus on and prioritize this aspect of our intervention. Therapists must capture this as billable time as they discover actions that create the most successful reactions, yielding to outcomes that are Medicare reimburseable such as "maximing function and safety." Once we discover the best "actions" and "therapeutic use of self," we teach this to others such as family members, nurses, CNAs, and activities. This becomes an important part of our mainteanance program.
A therapist may spend 5, 10, or even 15 minutes on this type of intervention during many treatment sessions as we do things such as:
Talk about the patients' past including family, work, and interests
Compliment the persons on how they look or who they are
Reassure them that they are with people who care about them and will keep them safe
Enable them to develop a relationship with you, other team members, and residents
All of this intervention is for the intent of gaining trust and agreement which can facilitate the use of the person's latent inner resources and abilities to maximize function and safety. This time, therefore, is billable and so is the time spent in "failure." If one of your planned interactions does not produce the reaction outcome you are trying to faciliate, it is still valuable and billable time. You have learned from this and will not repeat the same type of intervention or action. Of course, for these therapy intervention experiences to have the greatest value, we then go on to teach others what will work to faciliate the use of the patient's inner resources and what will not.
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In summary, therapists and others often to do not engage and hone their "therapeutic use of self" skills to the extent that they should be engaged when serving someone with ADRD. This may be a primary reason for so many failed therapeutic interventions. However, if the therapists do successfully implement their "therapeutic use of self" many do not give themselves the billable time credit. Remember that for reimbursement of this time, you must paint the picture as to what intervention was provided and WHY. Time spent using "therapeutic use of self" should be intentional, planned, and with "reactions" observed and noted. This then is linked in your notes directly to the goals of maximizing the person's function and safety. The CPT code selected for this time will relate to your professional intent (e.g., improvements in self-care, walking, or communication).
Start practicing using your "therapeutic use of self." I think you will be amazed at the better outcomes you achieve for your patients and the billable time you gain credit for. Start now.