Ch06

Chapter 6
Complexities Within Client-

Therapist Relationships: Inevitable
Interpersonal Events of Therapy
Copyright ©2020 F.A. Davis Company

Learning Outcomes
 Recognize the importance of interpersonal

events in shaping the therapeutic relationship.
 Define the 12 categories of interpersonal
events.
 Situate the role of interpersonal events within
the interpersonal reasoning process.
 Identify when an interpersonal event has
occurred and label that event.

Learning Outcomes (continued)
 Differentiate between therapeutic

relationships that are complicated and
uncomplicated.
 Discover how to mitigate an interpersonal
event cascade.

The (Inevitable) Interpersonal Events of
Therapy
 An interpersonal event is a naturally
occurring communication, reaction, process,
task, or general circumstance.
 Depending on how the therapist responds,
every interpersonal event that occurs during
therapy has the potential to weaken or
strengthen the therapeutic relationship.

Therapy (continued_1)
Strengthening Responses Weakening Responses
 Recognize that an event  Fail to recognize that an
has occurred. event has occurred.
 Identify the event  Recognize the event, but
(mentally) in your own underreact and decide
mind. to dismiss its potential
 Note the intensity of the importance, without
event precipitated by the paying attention to the
client or note the client’s client’s viewpoint.
response to the event.

Therapy (continued_2)
Strengthening Responses Weakening Responses
 Decide on your response  Overreact to the event, or
mode or set of modes. surface the event when
the client does not
consider it to be of
significance (or is not ready
to consider the event to be
of significance).
 Respond to the event
sub-optimally.

The 12 (Inevitable) Interpersonal Events
 Expression of strong  Boundary testing
emotion  Empathic breaks
 Intimate self-disclosure  Emotionally charged
 Power dilemmas therapy tasks and
 Nonverbal cues situations
 Verbal innuendos  Limitations of therapy
 Crisis points  Contextual
 Resistance and inconsistencies
reluctance

Expression of Strong Emotion
 Whether it is revealed or not, every

relationship is characterized by an emotional
experience.
 When a client’s expression is strong relative to
his or her general way of responding, or
completely absent relative to his or her general
way of responding (not relative to what you or
another person would consider strong), it calls
for pause.

Expression of Strong Emotion (continued)
 Sometimes the emotional experience is

shared between client and therapist.
 Other times, the client’s emotional experience
is solely his or her own.
• Anxiety
• Pervasive sadness
• Anger
• Restricted or absent emotion

Expression of Strong Emotion: An Example
 Kim encounters Peter, an accountant facing

multiple losses (refer to Feature Box 6.1 in
Chapter 6).

Think-Pair-Mingle
 Think about how you would have responded

to Peter if you were in Kim’s situation.
 Would you have done anything differently?
Be able to explain your answer.

Intimate Self-Disclosure
 All relationships require our clients (and

ourselves) to choose whether to reveal
something personal.
 Intimate self-disclosures occur when a person
discloses information to another person
because, at least in the moment, he or she has
decided that the person receiving the
information is trustworthy and deserving.

Intimate Self-Disclosure (continued_1)
 Self-disclosure is evident in . . .
• Our verbal information
• The stories we tell
• The jokes we make
• Our affect, tone of voice, and body language
• Physical appearance, style of dress, adornments,
and so on.

Intimate Self-Disclosure (continued_2)
 Clients can make an intimate self-disclosure to

their therapists.
 Therapists can choose to make an intimate self-
disclosure to their clients.
 When therapists make an intimate self-
disclosure to their clients, they place
themselves at risk for a suboptimal outcome.
 Both client and therapist self-disclosures carry
some degree of risk and should be considered
as interpersonal events.
Intimate Self-Disclosures From Clients
Optimal Outcomes Suboptimal Outcomes
 Affords the therapist  The client may be left
better understanding of with feelings of shame,
the client’s experiences. isolation, guilt, or anger
 Demonstrates that the for sharing his or her
client trusts in the thoughts, stories, and
therapist. feelings and not
receiving the response
he or she expected.

Intimate Self-Disclosures From Clients
(continued)
 If the therapist responds  The therapist may feel
successfully, the awkward, at a loss for
disclosure can lead to words, and/or may
feelings of mutuality or communicate
relief for the client. suboptimally.

Think-Pair-Share
 Think of a time when you disclosed

something personal to someone else and it
resulted in a positive outcome.
 What variables on your part, and on the part
of the person to whom you disclosed the
information, contributed to the positive
outcome?

Intimate Self-Disclosures From Therapists
 Reveals the therapist’s  Clients may experience
humanity/imperfection. the therapist’s disclosure
as uncomfortable or self-
 Could reveal a similarity
centered.
or similar experience to
 The therapist’s self-
that of the client, disclosure may lead the
creating some sense of client to ask additional
solidarity. questions that the
 Role modeling for the therapist is not
client that self-disclosure comfortable answering.
is welcomed.
Intimate Self-Disclosures From Therapists
(continued)
 The therapist uses  Clients may become
her/his/their story disillusioned or may have
to create a other unwanted feelings
teachable moment. about the therapist after
hearing the disclosure.
 Some clients, such as those
with certain types of
psychiatric overlay, may
misuse it to create a negative
situation for the therapist.

Think-Pair-Share (continued_1)
 Think of a time when you disclosed

something personal to someone else and it
resulted in a suboptimal outcome.
 What variables on your part, and on the part
of the person to whom you disclosed the
information, contributed to the suboptimal
outcome?

Intimate Self-Disclosure: Client Example
 Jake, a client with a spinal cord injury, shares

his true fears with Kim (refer to Feature Box
6.2 in Chapter 6).

Think-Pair-Mingle (continued_1)

to Jake if you were in Kim’s situation.

Power Dilemmas
 Every treatment relationship is characterized by

an undeniable power differential.
 The therapist is the gatekeeper of knowledge
and resources that the client needs.
 Most clients of occupational therapy will face
some form of discrimination, stigma, and
restricted access.
 The more loss of control experienced by the
client, the more disempowered the client may
feel.
Power Dilemmas (continued)
 Issues of power can manifest in passivity,

resistance, direct confrontation, and attempts
to control or manipulate.

Power Dilemma: An Example
 Nickolas, Jane’s client, demonstrated chaotic

and self-defeating habits, but did not
perceive it this way, and fought to maintain
his way of being despite others’ attempts to
intervene (refer to Feature Box 6.3 in
Chapter 6).


to Nickolas if you were in Jane’s situation.

Nonverbal Cues
 Facial expression, movement patterns,

posture, body language, proxemics, tone of
voice, eye contact, touch, dress, and
appearance all play a role in the therapeutic
relationship. It can be:
 A key, early source of communication on the
part of the client
 A means of enriching your knowledge of the
client

Nonverbal Cues (continued)
 A client’s way of conveying feedback

 A signal of a problem in the relationship
 A cause of a problem in the relationship
 A signal that the relationship is going well
 We will have a guest speaker next week to
discuss further about the area of non verbal
communication

Verbal Innuendos
 Communications in which the client says

something elusive or oblique that is meant
to serve as a hint about a more direct
communication.

Verbal Innuendo: An Example
 Margarita refers to her daughter as “a strong

one” (refer to Feature Box 6.5 in Chapter 6).

Think
 When reading about Margarita’s daughter’s

intrusion upon the hand therapy session,
how did you feel?
 If you were Kamisha, how would you have
reacted to Margarita’s comment, “She is a
strong one”?

Crisis Points
 Our lives are complex and filled with

unanticipated events.
 Points of crisis are common events in therapy
because clients may be experiencing multiple,
concurrent losses.
 They can be linked to actual life events.
 They can occur internally in some clients for
no conscious reason.

Crisis Points (continued)
 Therapists should be prepared to respond

effectively and adapt in such moments.

Crisis Points: An Example
 During the course of therapy, Virgil has a car

accident because of his problems with
alcohol.

Think
 Following the car accident, how would you

have resumed therapy with Virgil?
 What would you have said?
 What would you not have said?
 What modes are reflected in your reasoning?

Reluctance
 Occasionally, a client is reluctant to

communicate or to participate in the activities
of occupational therapy.
 If not explained directly, reluctance typically
manifests in terms of anxiety, passivity, or lack
of follow-through.

Reluctance (continued)
 Reluctance differs from resistance in that it

serves the client’s self-protective instincts and
cannot be attributable to a client’s underlying
interpersonal/self-sabotaging pattern or to
issues in the therapeutic relationship.

Client Reluctance
 Instead, reluctance may be undergirded by:

• Symptom escalation (client too fatigued today)
• Task perceived as too difficult or demanding
• Anxiety about task performance
• Fear of discomfort, pain, or being injured (e.g.,
falling)
• Values around health care (mistrust of the process)
• Low self-esteem, depression, feeling overwhelmed
 For these reasons, reluctance is usually quite
manageable using a range of modes.
Resistance
 Resistance is defined as:

• A client’s (conscious or unconscious) efforts to
refuse, skip, avoid, underperform, or fail to follow-
through with the tasks and recommendations of
therapy
 Does not make sense to others because it is:
• Typically maladaptive
• Deeply embedded
• Not reflective of the client’s best interests

Resistance (continued_1)
 Resistance may be attributable to:

• Relationships that the client is having with others
outside of therapy that are getting re-enacted
(nothing to do with the therapist)
• Issues within the client-therapist relationship (e.g.,
empathic breaks, rifts) (something to do with the
therapist)
• Selecting and then insisting on activities that a
client perceives are irrelevant to his or her life or
inconsistent with volition (interests, values,
causation) (a lot to do with the therapist)
• Or a combination of the previous items
Resistance (continued_2)
 Resistance may manifest in terms of:

• Direct refusal to do something
• Passive forms of refusal (actively ignoring the
therapist’s recommendations, being
uncommunicative or unresponsive)
• Challenging, questioning, or confronting the
therapist
• For these reasons, it is best approached by skillfully
combining empathy with problem-solving
approaches during an extended period of time.

Resistance: Client Example
 Abe, a 5-year-old with severe cerebral palsy,

would benefit greatly from the use of powered
mobility. Abe’s mother does not want him to use
powered mobility, and yet Abe experiences joy
and can participate in a wider range of activities
when using it (refer to Feature Box 6.7).

 Without worrying about the facts of what

may actually be going on with Abe’s mother,
what variables do you think may be
underlying Abe’s mother’s resistance?
 How would you approach Abe’s mother given
that she does not want Abe to use powered
mobility?

Boundary Testing
 Some clients will naturally test the limits of

their relationship with you.
 Other clients may be confused about the
nature of their relationship with you.
 These clients usually have difficulties figuring
out what the boundaries are to other
relationships, as well.

Boundary Testing (continued_1)
 May manifest in
• Asking inappropriately intrusive or personal
questions
• Making inappropriately personal statements in
your presence or in the presence of others
• Acting too familiar or casual with someone who
does not regard the relationship similarly
• Making insensitive or uncouth statements in your
presence or in the presence of others

Boundary Testing (continued_2)
• Inappropriately touching you, others, or things
that belong to you or others
• Using, without permission, things that belong to
you or others

Boundary Testing: Client Example
 Ernesto has feelings toward his son’s

therapist, Carmen (refer to Feature Box 6.8
in Chapter 6).


to Ernesto if you were in Carmen’s situation.
 Share your thoughts with your partner.

Empathic Breaks
 Necessary “misses” that occur in any

relationship
• Therapist demanding too much
• Therapist being too directive or the opposite
• Disruption in therapy caused by therapist illness,
vacation, pregnancy, or cancellation
• Enforcement of professional boundaries or time
limits
• Unintentionally saying the wrong thing
• Not responding to a client in a way he or she would
have wanted

Empathic Breaks: An Example
 Sharing findings from the AMPS with Madam

Roucharlamange (refer to Feature Box 6.9
from Chapter 6).

Think-Mingle-Share

to Madam Roucharlamange if you were in
René’s situation.
Explain your answer.

Emotionally Charged Therapy Tasks
 Occupational therapy presents a lot of

situations that are potentially emotionally
charged for clients.
• Learning to eat for the first time and eventually
eating in public for the first time
• Toilet retraining
• Failures in attempting to perform activities that
once came naturally
• Failures in attempting to perform once-cherished
activities

Emotionally Charged Therapy Tasks: An
Example
 Howard’s statements that he cannot do
things and his mother and sister’s
corresponding laughter (refer to Feature Box
6.10 in Chapter 6).

Think-Mingle-Share (continued)

to Howard, his mother, and his sister if you
were in Vardit’s situation.
 Would you have done anything differently
than Vardit?

Limitations of Therapy
 All relationships are limited by mismatches,

time, setting demands, payment/insurance
issues, professional boundaries, and other
limitations imposed by the necessities of our
shared human experience.
 Sometimes these limits have positive outcomes
or serve a protective purpose within the
relationship.
 Other times they prevent a crucial achievement
or outcome in therapy.
Limitations of Therapy: An Example
 Kim Muir faces insurance limitations (refer to

Feature Box 6.11 in Chapter 6).

 Think of a time when you or a family

member/friend faced a limitation in some
type of treatment or educational help that
was needed.
 What, if anything, was said or done to
mitigate the limitation?
 What, if anything, could have been said or
done to mitigate the limitation?

Contextual Inconsistencies
 May pose challenges to the natural flow and

routine of therapy
 Any aspects of a client’s physical or personal
environment that change during the course of
therapy
 Some clients may be thrown by changes from
week to week in treatment room, number of
people or who is in the waiting room, and so
on.

Contextual Inconsistencies: An Example
 The author’s presence during the therapy

sessions was featured in this text (refer to
Feature Box 6.12 in Chapter 6).

Interpersonal Event Cascade
 Though interpersonal events are natural and

should not be considered a negative aspect
of the therapeutic relationship, if they are
not responded to optimally, an interpersonal
event cascade is likely to occur, particularly if
a client is vulnerable or sensitive.

Interpersonal Event Cascade (continued)
 An interpersonal event cascade occurs when

more than one interpersonal event occurs
during a single interaction, and those events
appear to be connected by a single theme
and a predominant emotion.

Interpersonal Event Cascade: Client
Example
 A client finds the therapist’s Facebook page
on the Internet and sends a friend request to
the therapist (boundary testing).
 The therapist fails to accept the friend request
(limitations of therapy).
 The therapist ignores that anything has
happened and proceeds with therapy
(empathic break).

Interpersonal Event Cascade: Client
Example (continued)
 The client refuses to participate in any of the
therapeutic activities during the next session
(resistance).
 The therapist comments on the client’s
refusal, and the client abruptly leaves,
slamming the door behind her (expression of
strong emotion).

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Chapter 6

Complexities Within Client-

Copyright ©2020 F.A. Davis Company

 Recognize the importance of interpersonal

Copyright ©2020 F.A. Davis Company

 Differentiate between therapeutic

Copyright ©2020 F.A. Davis Company

Copyright ©2020 F.A. Davis Company

Copyright ©2020 F.A. Davis Company

Copyright ©2020 F.A. Davis Company

Copyright ©2020 F.A. Davis Company

 Whether it is revealed or not, every

Copyright ©2020 F.A. Davis Company

 Sometimes the emotional experience is

Copyright ©2020 F.A. Davis Company

 Kim encounters Peter, an accountant facing

Copyright ©2020 F.A. Davis Company

 Think about how you would have responded

Copyright ©2020 F.A. Davis Company

 All relationships require our clients (and

Copyright ©2020 F.A. Davis Company

Copyright ©2020 F.A. Davis Company

 Clients can make an intimate self-disclosure to

Copyright ©2020 F.A. Davis Company

Copyright ©2020 F.A. Davis Company

 Think of a time when you disclosed

Copyright ©2020 F.A. Davis Company

Copyright ©2020 F.A. Davis Company

 Think of a time when you disclosed

Copyright ©2020 F.A. Davis Company

 Jake, a client with a spinal cord injury, shares

Copyright ©2020 F.A. Davis Company

 Think about how you would have responded

Copyright ©2020 F.A. Davis Company

 Every treatment relationship is characterized by

 Issues of power can manifest in passivity,

Copyright ©2020 F.A. Davis Company

 Nickolas, Jane’s client, demonstrated chaotic

Copyright ©2020 F.A. Davis Company

 Think about how you would have responded

Copyright ©2020 F.A. Davis Company

 Facial expression, movement patterns,

Copyright ©2020 F.A. Davis Company

 A client’s way of conveying feedback

Copyright ©2020 F.A. Davis Company

 Communications in which the client says

Copyright ©2020 F.A. Davis Company

 Margarita refers to her daughter as “a strong

Copyright ©2020 F.A. Davis Company

 When reading about Margarita’s daughter’s

Copyright ©2020 F.A. Davis Company

 Our lives are complex and filled with

Copyright ©2020 F.A. Davis Company

 Therapists should be prepared to respond

Copyright ©2020 F.A. Davis Company

 During the course of therapy, Virgil has a car

Copyright ©2020 F.A. Davis Company

 Following the car accident, how would you

Copyright ©2020 F.A. Davis Company