Interpersonal events 1.0
Unanticipated, stressful events that cause clients to become distracted or that temporarily interfere with client's ability for occupational engagement
Ex: change in health status or change in relationship
Crisis points
For the past six months, you have been working with Glenn on self-care issues following a stroke. Because Glenn has no family support and few friends, you have become his only source of emotional support, and he has developed a strong bond with you. However, you have decided to take a leave of absence from the outpatient center to pursue further training to support your own professional development. You know that Glen is not yet ready to discontinue therapy and you also know that he may have difficulty forming a bond with a new therapist at first. Still you have to tell him that you will be leaving in approximately 2 months. When you tell him of this anticipated change, he wishes you the best and says you deserve to further your career. He says he is OK with the news because you have given him two months to prepare for it. However, during the session, you observed that he is visibly trembling.
Limitations of therapy; Nonverbal cue
Client behavior that violates or that asks the therapist to act in ways that are outside the defined therapeutic relationship
Boundary testing
Alice is a woman in her early 60s who has lupus and a secondary depressive disorder. You are leading a group on stress reduction for individuals with chronic illness, and the topic of the conversation focuses on occupations that reduce stress. Toward the beginning of the session, Alice looks sullen and sits, her eyes cast downward. When it comes time for you to encourage her to provide input, she reports that she has nothing to contribute. Another group member jumps in and attempts to coax Alice by suggesting she tell the group about her past career as a veterinarian. Alice responds by telling the group member that she has no business making that suggestion and continues to not make eye contact with anyone
Nonverbal cues; power dilemma
Communications that do not involve the use of formal language
Nonverbal cues
Doris is a 54-year-old woman with post-stroke hemiplegia and unilateral neglect who has been attending therapy for several weeks. From week to week Doris's affect appears to facilitate from being relatively flat to being irritable and, at times, angry
Expression of strong emotion
Disinclination toward some aspect of therapy for reasons outside the therapeutic relationship
Reluctance
Any aspects of a clients interpersonal or physical environment that change during the course of therapy
Contextual inconsistencies
Statements or stories that reveal something unobservable, private, or sensitive about the person making the disclosure
Intimate self disclosures
Gloria is a three-year-old girl with auditory and visual processing difficulties as well as motor planning difficulties. After she and her mother sat in traffic for an hour, she arrived at the session sobbing and crying. Her mother reported that Gloria was probably crying because she sensed how stressful it was for her mother to sit that long in traffic and arrive late to therapy. As Gloria's therapist, it takes you 5 minutes before you can soothe and distract her enough to get her interested in therapy
Expression of strong emotion
Restrictions on the available or possible services, time, resources, or therapist actions
Limitations of therapy
Judy, 45-year-old women, has been working with you for the past two months following a spinal cord injury that occurred in a motorcycle accident. Since she began rehabilitation, she has exhibited a take-charge attitude about her therapy and has participated actively in choosing and pursuing goals for rehabilitation. One day, she receives news that a close friend and family member of her biking group suddenly died of a heart attack, she appears stunned from that moment on she discontinues all communication with you exhibits a mask-like expression and stops working on any of her therapy goals
Crisis point and expression of strong emotion
Esther and her four-year-old daughter Angie, who has an autistic spectrum disorder, have been seeing you weekly for two months. Before that, Esther and Angie had been working with a more experienced therapist who had since left the clinic. In one session, Esther expresses disappointment in Angie's lack of progress. You respond by asking Esther if she has been following through with the play activities for Angie that you have been recommending as homework. Esther returns an angry look.
Empathic break; nonverbal cue
Occurs when a therapist fails to notice or understand a communication from a client of initiates a communication or behavior that is perceived by the client as hurtful or insensitive
Empathic breaks
It is the therapist's third session with an 8-year-old child, Nick, who has an autistic spectrum disorder. The therapist has identified several sensory problems in the child. She explains them to the mother and confidently recommends a sensory diet for the child. As the occupational therapist begins to describe what would be involved, the child's mother, who is about 10 years older than the therapist, gives the therapist a nervous and incredulous look and asks, “Have you ever done this on your kids?” and then chuckles nervously and says “assuming that you have kids?”
Limitations of therapy; power dilemma; reluctance
Tensions that arise in the therapeutic relationship because of client's innate feelings about issues of power, the inherent situation of therapy, the therapist's behavior, or other circumstances that underscore client's lack or loss of power regarding aspects of their lives
Power dilemmas
Kenta is a 5-year-old boy with autism who is intellectually gifted in the areas of reading, music, and mathematics. He is the son of successful dual-career parents. His mother, Mrs.Nakamura, is a well-educated international businesswoman. In therapy, Kenta has been working on affect regulation, gross and fine motor skills, and social skills with his occupational therapist for the past six months. Overall, Kenta's parents have been pleased with Kenta's progress. However, it has been difficult for them to take Kenta to the therapy sessions regularly and on time because of their busy schedules. Following one particularly rich therapy session with Kenta, Mrs. Nakamura asked the therapist if she might leave Kenta in the gym at the clinic to study his reading while the therapist sees other clients after the next therapy session for the remainder of the afternoon. The therapist apologized and explained that the clinic does not offer childcare and that it would be against the clinic's policies to leave him in the gym without one-on-one attention. Mrs. Nakamura then remarks “yes you are watchful aren't you?”
Boundary testing, limitations of therapy, verbal innuendo
External displays of internal feelings that are shown with a level of intensity beyond usual cultural norms for interaction
Expression of strong emotion
Clark, an elderly client with a developmental disability and diabetes, is pacing the hallways, appearing upset, and gesturing with his arms. Earlier that morning, he arrived at the day center and found that the center room in the basement, which he normally enjoys visiting first thing in the morning, had been closed off and disassembled because of a flood. When the therapist tries to explain what happened and comfort him, Clark asks if he can have some cake, a food he knows his doctor has prohibited because of his diabetes.
Expression of strong emotional contextual inconsistencies; boundary testing
Activities or circumstances that can lead clients to become overwhelmed or experience uncomfortable emotional reactions such as embarrassment, humiliation or shame
Emotionally charged therapy tasks and situations
You are working in an inpatient unit. Bob, one of your clients, is a 36-year-old man with severe injuries to his wrists and left leg from a car accident. On occasion, you have noticed that his wife appears exceptionally worried about him, yet there is some tension in the relationship. During one of your sessions, you raised a question about sources of support following discharge, and after some discussion, Bob confides in you that although he hasn't yet told his wife, he had been planning to raise the issue of divorce with her before his accident.
Intimate self disclosure
Communications in which the client says something illusive or oblique that is meant to serve as a hint about a more direct communication
Verbal innuendos
When you meet Mike, it is evident from his appearance and ordor that he does not practice adequate hygiene. It is also clear that you do not know how to manage the issue with Mike. His mother mentions that every time she raises the issue, he becomes defensive and tells her she is overreacting. You are faced with a situation in which you must discuss these issues with Mike, who seems disinterested and unaware of his hygiene problems.
An emotionally charged therapy situation
Stephanie is an 85-year-old nursing home resident with mild dementia, a visual impairment, and pernicious anemia. Earlier in the week, she requested to go on a community outing with the other residents, but her doctor refused to give her medical clearance because of concerns about an upper respiratory infection from which she was recovering. As an alternative you encourage her to accompany you you to the cafeteria to play bingo a game you know she enjoys. she tells you that she doesn't want to play this week and asked if she can participate in the art therapy group instead. although art is not an activity in which Stephanie has ever expressed an interest in she does not know the art therapist just before the group begins you get special permission from the art therapist and allow Stephanie to join the art therapy group. however, instead of participating in the group you find her wandering in the corridor. when you ask her why she is not in the group she tells you she is disinterested. when you encourage her to come back to play bingo, she refuses
Power dilemma; resistance; boundary testing
A client's passive or active refusal to participate in some or all aspects of therapy for reasons linked to the therapeutic relationship
Resistance