Chapter 6
Complexities Within Client-
Therapist Relationships: Inevitable
Interpersonal Events of Therapy
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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.
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Learning Outcomes (continued)
Differentiate between therapeutic
relationships that are complicated and
uncomplicated.
Discover how to mitigate an interpersonal
event cascade.
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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.
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The (Inevitable) Interpersonal Events of
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.
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The (Inevitable) Interpersonal Events of
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.
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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
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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.
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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
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Expression of Strong Emotion: An Example
Kim encounters Peter, an accountant facing
multiple losses (refer to Feature Box 6.1 in
Chapter 6).
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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.
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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.
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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.
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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.
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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.
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Intimate Self-Disclosures From Clients
(continued)
Optimal Outcomes Suboptimal Outcomes
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.
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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?
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Intimate Self-Disclosures From Therapists
Optimal Outcomes Suboptimal Outcomes
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.
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Intimate Self-Disclosures From Therapists
(continued)
Optimal Outcomes Suboptimal Outcomes
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.
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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?
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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).
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Think-Pair-Mingle (continued_1)
Think about how you would have responded
to Jake if you were in Kim’s situation.
Would you have done anything differently?
Be able to explain your answer.
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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.
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Power Dilemmas (continued)
Issues of power can manifest in passivity,
resistance, direct confrontation, and attempts
to control or manipulate.
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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).
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Think-Pair-Mingle (continued_2)
Think about how you would have responded
to Nickolas if you were in Jane’s situation.
Would you have done anything differently?
Be able to explain your answer.
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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
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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
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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.
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Verbal Innuendo: An Example
Margarita refers to her daughter as “a strong
one” (refer to Feature Box 6.5 in Chapter 6).
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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”?
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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.
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Crisis Points (continued)
Therapists should be prepared to respond
effectively and adapt in such moments.
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Crisis Points: An Example
During the course of therapy, Virgil has a car
accident because of his problems with
alcohol.
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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?
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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.
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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.
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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.
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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
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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
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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.
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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).
Copyright ©2020 F.A. Davis Company
Think-Pair-Mingle (continued_6)
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?
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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.
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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
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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
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Boundary Testing: Client Example
Ernesto has feelings toward his son’s
therapist, Carmen (refer to Feature Box 6.8
in Chapter 6).
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Think-Pair-Share (continued_2)
Think about how you would have responded
to Ernesto if you were in Carmen’s situation.
Share your thoughts with your partner.
Would you have done anything differently?
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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
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Empathic Breaks: An Example
Sharing findings from the AMPS with Madam
Roucharlamange (refer to Feature Box 6.9
from Chapter 6).
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Think-Mingle-Share
Think about how you would have responded
to Madam Roucharlamange if you were in
René’s situation.
Share your thoughts with your partner.
Would you have done anything differently?
Explain your answer.
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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
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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).
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Think-Mingle-Share (continued)
Think about how you would have responded
to Howard, his mother, and his sister if you
were in Vardit’s situation.
Share your thoughts with your partner.
Would you have done anything differently
than Vardit?
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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.
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Limitations of Therapy: An Example
Kim Muir faces insurance limitations (refer to
Feature Box 6.11 in Chapter 6).
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Think-Pair-Share (continued_3)
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?
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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.
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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).
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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.
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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.
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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).
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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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