Danish Therapy Questionnaires Reveal Gaps Between What Clients Prefer and Therapists Deliver

Every occupational therapy encounter rests on an invisible foundation: the therapeutic relationship. What a therapist says, how they listen, and the way they structure a conversation can shape whether a client engages fully or quietly disengages. A new Danish study now offers one of the most detailed looks yet at whether a set of structured questionnaires can actually help therapists and clients talk about that relationship, and whether the two sides even see it the same way. The findings, published in the Scandinavian Journal of Occupational Therapy, are both encouraging and quietly unsettling.

The study, led by Kristina Tomra Nielsen and colleagues as part of the Danish Intentional Relationship Model research program, set out to evaluate the clinical utility of three Danish-language questionnaires known collectively as the D-CAMQs. These instruments are adapted from the Clinical Assessment of Modes, developed by Renee Taylor to operationalize her Intentional Relationship Model. That model proposes that therapists draw on six distinct interpersonal communication styles, called therapeutic modes: Advocating, Collaborating, Empathizing, Encouraging, Instructing and Problem-solving. Advocating means helping clients access community resources; Collaborating shifts decision-making power to the client; Empathizing involves non-judgmental validation of thoughts and feelings; Encouraging instills hope and courage; Instructing structures, teaches and provides feedback; and Problem-solving guides clients through strategic reasoning about options. According to the model, no single mode is superior, and skilled therapists shift fluidly between them depending on what each client needs in the moment.

To capture how these modes play out in real therapy, the Clinical Assessment of Modes comes in three parts. Before therapy begins, clients complete the CAM-C1, rating how important each mode is to them on a five-point importance scale. After therapy concludes, clients fill in the CAM-C2, reporting how frequently they perceived their therapist actually using each mode. In parallel, the therapist completes the CAM-T, describing their own perception of how often they used each mode with that specific client. The Danish research team had previously translated and culturally adapted all three questionnaires following international guidelines for patient-reported outcome measures, establishing face validity and cultural relevance. What remained unknown was whether the instruments would function usefully in day-to-day clinical practice, not just in the psychometric laboratory.

Clinical utility, in this context, is a four-dimensional concept drawn from Andrew Smart’s multi-dimensional model. Appropriateness asks whether the instrument is relevant and improves clinical decision-making. Accessibility weighs the resources required, especially time, against the benefits gained. Practicability concerns whether instructions and functionality work smoothly, and acceptability addresses ethical, social and psychological concerns around use. The Danish team designed parallel surveys for clients and therapists, each mapped onto these four dimensions, and embedded the questionnaires into genuine therapy courses rather than staged research encounters. Clients completed their pre-therapy questionnaire at the first session, and therapists used the clients’ stated preferences to frame an explicit conversation about how they would work together. At the final session, clients reported on what they had experienced, and the paired results were discussed openly.

Eleven occupational therapists and forty-seven clients aged 23 to 97 took part, recruited from settings ranging from acute hospitals and municipal rehabilitation to psychiatry, home care and specialized neurorehabilitation. Most clients had been referred for neurological conditions. The therapists were all women and none had prior familiarity with the Intentional Relationship Model, making them genuine newcomers to the framework. Recruitment, originally targeting thirty therapists, was hampered by the COVID-19 pandemic, a constraint the authors acknowledge as a major limitation that renders the study exploratory rather than definitive.

The descriptive results painted a coherent picture. Clients rated all six modes as relevant, with median importance scores ranging from 15 to 20 out of a possible 25. Instructing emerged as the most important mode, while Advocating ranked lowest, a pattern echoed in the post-therapy ratings, where clients perceived frequent use of five modes but only occasional use of Advocating. Therapists’ self-ratings followed the same shape, with Advocating rarely used. At the group level, clients and therapists appeared to agree: no obvious discrepancies surfaced between the median profiles.

But when the researchers moved from group medians to individual-level statistics, a more complicated story emerged. Correlations between clients’ preferred modes before therapy and their perceived mode use afterward were moderate to weak, with Spearman’s rho values between 0.26 and 0.48. More strikingly, agreement between clients’ perceptions of mode use and therapists’ self-reported use was weak to trivial, and some correlations were negative, meaning that when a client perceived a mode being used more often, the therapist sometimes reported using it less. In other words, therapists and clients sitting across from each other for weeks of therapy frequently disagreed about the very communication style that defined their collaboration. The authors interpret this cautiously, noting that preferences and perceptions come from different perspectives and may converge differently, but they emphasize that such single-case discrepancies underscore why continuous dialogue about communication is essential rather than optional.

On the utility surveys, clients were largely enthusiastic. Fifty-seven percent felt it was highly relevant to share their communication preferences before therapy, 44 percent found it highly relevant to report and discuss experiences afterward, and 51 percent said discussing preferences significantly shaped the therapy process. Sixty percent judged the time spent on these discussions to be well justified by the benefits, 61 percent found the questionnaire instructions highly sufficient, and 86 percent reported no challenges discussing their preferences with their therapist. Acceptability exceeded 80 percent across both groups.

The therapists were harder to win over. Only 14 percent considered knowledge of client preferences highly relevant to specific therapy processes, and not a single therapist rated information about client experiences as highly relevant for future collaborations. Nearly half felt the time clients spent completing two full questionnaires was not matched by the insight gained, although 86 percent considered their own completion of the therapist form at least somewhat worthwhile. Free-text comments revealed practical friction: some clients, particularly those with cognitive challenges, were overwhelmed by the number of questions or misunderstood the items, requiring substantial assistance. Still, the therapists broadly endorsed the instruments’ acceptability, with one noting that the process had given her direct insight into what worked in individual patient courses, what to attend to, and what to do more or less of in her own therapeutic style.

The study’s significance lies less in any single number than in what it demonstrates about measuring something as elusive as interpersonal style. Structured questionnaires can open a conversation that might otherwise never happen, giving clients a legitimate voice in how they are treated and giving therapists a mirror for their own habits. The Danish versions of the Clinical Assessment of Modes questionnaires appear fit for that purpose, particularly the pre-therapy form, which seems well suited to framing the initial collaboration. At the same time, the authors caution that knowing a client’s preferences will not automatically change the relationship; therapists need deeper training in the six modes and in deliberately shifting between them to avoid suboptimal patterns such as mixing modes or missing a client’s needs entirely. With a small, pandemic-constrained sample and no prior IRM knowledge among participating therapists, the findings demand confirmation in larger, more representative studies, ideally supplemented by qualitative interviews. But the core message stands: clients and therapists do not always perceive the same therapy, and giving both sides a structured way to compare notes may be one of the most practical steps toward genuinely client-centred care.

Subject of Research: Clinical utility of Danish versions of the Clinical Assessment of Modes questionnaires in occupational therapy practice

Article Title: Clinical utility of the Danish versions of the Clinical Assessment of Modes Questionnaires

Article References: Nielsen, K. T., Pilegaard, M. S., Larsen, A. E., & Wæhrens, E. E. (2025). Clinical utility of the Danish versions of the Clinical Assessment of Modes Questionnaires. Scandinavian Journal of Occupational Therapy, 32(1), 1-12. https://doi.org/10.1080/11038128.2026.2615565

Image Credits: AI Generated

DOI: 10.1080/11038128.2026.2615565

Keywords: occupational therapy, therapeutic relationship, Intentional Relationship Model, therapeutic modes, clinical utility, questionnaires, client-therapist discrepancy, communication, psychometrics, Denmark, client-centred practice, rehabilitation