What started out as a straightforward project turned into an intense immersion into the process of doing research. Having recently been introduced to the field of experimental psychology, I wanted to incorporate my interest in occupational therapy into research I was conducting for my Psychology major. Specifically, I wanted to explore the relationship that exists between therapists and their clients. A majority of previous research (Rosa & Hasselkus, 1996; Cook & Moll, 1997; Lyons, 1997) had used largely qualitative observations to support their hypotheses on effective therapeutic relationships.

Quantified research was missing. I was captivated by the idea of translating these abstract and complex human interactions into objective, unbiased numbers. But while numbers can be manipulated, human beings cannot. Conducting my research with elderly participants, I realized that this is both the beauty and drawback of working with a special population. So when plans were not working out, the methodology, and not the participants, had to bend. I learned how to stay flexible, to constantly re-evaluate my approach, to hang on to optimism. Most importantly, I learned to value the individuality of the participants, and the fact that they were not responding the way I had pre-conceived. The process of the research, and not the final statistical analyses, became my end-goal.

Working with geriatric patients, I had to quickly revise or abandon much of my original methodology. Finding older participants initially posed a problem. Facilities seemed reluctant to allow me access to their patients, and only upon detailed explanation, and a tuberculosis test, could I start my research. I also learned that I had greatly underestimated participants' level of physical impairment. Many participants were very old (several were over 85, one participant was 100 years old) and had moderate to severe deficiencies in eyesight and dexterity. The tasks that I posed had to be greatly simplified so that participants could complete them. Questionnaires had to be administered orally because almost all participants could no longer read nor write. With each delay and obstacle, obtaining clear-cut data became less important. Instead, I began to focus on the experiential value of the research.

The idea of the current study was originally generated from an internship experience. The internship, in the field of physical therapy, stimulated curiosity about what made a therapeutic relationship effective. Observations during the internship led to the initial hypothesis that the type of relationship a patient has with the therapist could be key in influencing the success of the therapy. Specifically, it was thought that how much and how closely a therapist interacts with her patient would determine how well a patient recovered. Patients who had close relationships and more interactions with their therapists seemed to be more dedicated in coming to their appointments and improved faster. Patients who seemingly did not connect as well with their therapists appeared to have a slower recovery rate. They seemed to have less progress in their therapy, coming for longer periods of time. These patients also tended to have more cancellations than did other patients.

In deciding on a thesis project, the goal was then to 'translate' a therapeutic relationship into an 'experimenter-participant relationship' which could be tested in a laboratory setting. Since interaction over a physical activity is essential to physical and occupational therapy, the researcher sought to devise an activity which would allow interaction with participants, could be completed relatively easily, but also allowed room for improvement. In therapy, games are often used to generate a client's interest in her rehabilitation and to provide a medium for therapist-client interactions. These interactions are important not only for physical but also emotional rehabilitation as the challenge of the activity encourages clients to express frustrations and feelings about their condition. The researcher decided to build her methodology around an activity involving a parquetry assembly board used in occupational therapy.

Another internship, this time in occupational therapy, familiarized the experimenter with the parquetry assembly board, a three-dimensional geometric wooden block puzzle. For this task, blocks are assembled into a specific pattern using two-dimensional color design cards. Various levels of difficulty for the cards are available. Because the completion of a puzzle took a fair amount of time, it allowed for more interaction between participants and experimenter. Using the assembly board, the researcher could give participants more in-depth performance feedback as well as hold casual conversations during set-up and takedown of the puzzle.

Feedback could include discussion of block laying techniques which had worked especially well for the participant, such as laying all the blocks of one color first before moving on to the next color of blocks. Well-placed comments could communicate greater care and interest for a participant if the experimenter used active-listening skills and attentive body language. This may have in turn facilitated further conversation because participants may have felt more at ease with the experimenter. It was hoped that increasing interaction with participants would help develop a more in-depth rapport between researcher and participant. By defining two levels of interaction, one with limited interaction and one with increased emotional interaction, changes in the quality and improvement of performance were expected to be evident with increasing interaction.

For the primary study conducted in the spring, an initial meeting with each potential participant was set up before testing was started. During this visit, the researcher explained the general research methodology, had participants provide written consent, and also allowed participants to practice the block assembly board. The first experimental session was scheduled, and participants were informed that another researcher would also be visiting at that time in order to ask them confidential questions. Participants were then divided into two groups - Emotional Interaction group and Physical Interaction group. For the Emotional Interaction group, the goal was to develop a closer rapport between participant and experimenter. For the Physical Interaction group, interaction was limited so that a close rapport would be less likely to develop.

During the following session, participants were first asked to respond to a depression questionnaire. A research assistant orally administered the questionnaires after the main researcher had left the room; the researcher was not present during the questioning. Each participant was also given a copy of the questionnaire in large (14 point bold font) print so that they could read along with the researcher.

After the depression questionnaire was completed, participants met the researcher in the dining hall where a flat table was available for the block assembly. It is important to note that the dining hall was set off from the rest of the retirement center and was empty during the sessions, providing privacy during testing.
For the Emotional Interaction group, after a period of leisurely conversation, participants were given parquetry block design A to complete. All performances was timed. During the session, the experimenter sat in close proximity to the participant and would occasionally interject short comments of encouragement and feedback as the participant completed the design (e.g. "Good." "That's right." "Well done.") Longer feedback was avoided during the design completion so that the participant would not be distracted from the task.

After the session, the experimenter would highlight techniques which seemed to have helped the participant or had worked especially well for them. The researcher verbally administered a session evaluation questionnaire which investigated participants' feelings towards the activity, how much participants felt they had improved, and how stressful the activity was for them. The researcher then spent up to 20 minutes in general conversation with the participant, asking them about their daily activities, plans for the week, their family and friends, their memories.

For the Physical Interaction Group, interaction before and after sessions was limited as much as possible. The researcher tried to restrict the amount of personal information she shared, as well as the interest she showed towards participants (e.g. not asking them as many questions about their lives). During the sessions, after setting up the puzzle, the researcher sat across the room from the participant, still in eye range but not in full view. The researcher would engage in seeming "work," ignoring the participant during the block assembly.

These block design sessions were completed twice more: for the second experimental session, block design B was completed, and for the third session, block design A was again administered. After the final session, the same assistant once again administered the depression questionnaire; participants were additionally asked a series of questions to evaluate the experimenter and the overall research process.

After all data had been collected, the researcher set up a last appointment with participants for a debriefing session. Debriefing was scheduled as an informal visit, and the researcher brought flowers, cookies and a thank-you card to participants. The experimenter explained the research to participants in more detail, and any questions were answered. The rest of the session was spent in friendly conversation to ensure pleasant memories of the research experience for all participants.

While the current study could not conclusively support its original hypothesis, it did provide insights into working with older persons. Small sample sizes (there were only 4 participants in the spring study) as well as confounding of interaction levels made data collection difficult. Although the data could not be generalized to geriatric populations, they do reveal trends which suggest that interaction with the researcher could influence at least the emotional well-being of a participant. This research also identified many variables which make research with older people difficult, and is therefore invaluable as a pilot study in the area of task performance.

Initially this project set out to provide quantitative data to support an emerging humanistic approach within occupational therapy. Past research (Rosa & Hasselkus, 1996; Cook & Moll, 1997; Lyons, 1997) has established the need for a greater patient-therapist rapport with qualitative observations and anecdotal data. However, significant quantitative data were missing which would support the thesis that effective therapy is linked to the type of relationship a therapist has with her client.
The current study investigated these trends within an aging population. Results of the project highlighted why quantitative data were hard to find and why researchers have depended largely on qualitative observations especially for geriatric populations (Ronnberg, 1998; Hatfield, 1999; Glaser, 1998): One of the main difficulties in working with elderly participants was their chronic illnesses and general decline in health. Because the aged varied greatly in their degree of physical impairment, consistent collection of data was difficult. For some participants, assigned tasks may have been too difficult while for others the task may have been too easy. If the task was beyond their level of ability, participants easily became frustrated; if the task was too simple in nature, participants quickly became bored.

Another difficulty in working with the aged is that in general, residents in nursing homes do not receive a lot of individualized attention (see Ronnberg, 1998). Any attention that the researcher therefore gave to participants, regardless of how little, may have seemed important to them. Keeping stringent differences between levels of interaction was therefore nearly impossible to maintain in the current study. It is plausible that if the levels of interaction could have been kept separate, trends in the data would have reached significance, supporting the study's original hypothesis.

This research was nevertheless valuable for me personally. One of the greatest values of this research experience was that it helped prepare me for a possible future career in occupational therapy. I experienced firsthand some of the trials that accompany work in retirement facilities. Because of the relationships that I developed with participants, many of them felt at ease sharing their frustrations with me about their life in a nursing home. This intimate glimpse into their struggles will hopefully help me to be sensitive to clients that I may some day be working with.

The experience also strengthened my communication skills. I learned how to speak clearly with participants and to discern how to communicate best with participants who were hard of hearing. Elderly participants seemed especially confused by technical language, and I learned to translate my study into laymen's terms. I also noticed that participants seemed to take cues from my body language and voice inflection. If I seemed more at ease and positive, participants seemed to relax and be more willing to complete research requirements. On days where I was more stressed and less sure of how I was going to conduct the session, participants also seemed to feel less at ease. Bedside manner seems extremely important when working with the elderly.

Interacting with the staff and directors of nursing homes additionally helped me improve my ability to communicate and be assertive. I needed to learn a certain diplomacy in order to reassure the nursing homes of my intentions and the purpose of the research. As I spent time with the staff, their views of work in nursing homes made me realize the necessity for extreme patience, and a positive outlook, in their field of work.

The experience I gained from this research will likely have far reaching effects both in my personal and professional life. My work allowed me to explore the field of psychological research while gaining information and developing skills which will be helpful in a career emphasizing the importance of patient-therapist relationships.

From a research point of view, and from the participants' perspective, the study was worth conducting. Overall, despite the problems this study encountered, the research provided useful information. Trends in all four studies consistently suggested that the amount of the experimenter's interaction affected the participant's degree of physical and emotional improvement. The strongest indication for this is again qualitative anecdotes, rather than quantitative data.

Participants' comments at the close of the study highlight how important the relationship with the experimenter had become to them. Almost every participant expressed regret that sessions had ended, and wanted me to continue visiting him or her. One of the participants from the spring Emotional Interaction group observed that what she had appreciated most was my listening to her, and my genuine interest in what she was saying. This participant had experienced a recent fall, and during one block assembly session, chose to discuss her feelings about her accident. Our interaction seems in-line with the way occupational therapy uses activities, such as the assembly board, to encourage conversation about one's disabilities.

This situation is just one example in which a participant's comments confirmed that I had actually communicated the interest I intended to show. Encountering a person who cared about her created a safe atmosphere for discussing her problems. This sharing could be an important step towards emotional well-being. So for this participant, as for others, the research made a difference.

This research is only the beginning then, having barely delved beneath the surface of what makes a therapeutic relationship effective. Ideas and methodology underwent many changes in order to define the structure of the current study. I would be excited if the project would continue to evolve, and this research could become a master's thesis some day. For me, understanding the essence of effective therapy is essential to improving patient care.