periods marked by a significant challenge and/or change. Moreover, clients who are long-term participants in ther- apy are periodically faced with significant challenges. Some clients have the internal strengths and coping mech- anisms to weather the changes and challenges associated with therapy. Some have extensive social support networks that bolster their ability to manage change and challenges (Fig. 5.8).
Other clients, however, without the same internal and/or external resources have more difficulty managing the stress associated with change and significant chal- lenges. Some clients have difficulty with even minor change and challenges. For example, some more sensitive clients may experience difficulty with changes in the ther- apy schedule, in the way the therapy room is arranged, or in the way the therapist looks or behaves on a given day.
At some point during the therapy process, most clients encounter some difficulty coping and adjusting to change and challenges. This is particularly true during long-term therapy relationships when challenges and frus- trations are inevitable over time. When clients have diffi- culty with change and challenges, they may exhibit any of the following behaviors in anticipation of therapy activi- ties or events.
FIGURE 5.7 Kristin Alfredsson Ågren encourages and coaches a client on how to assert needs while at the day center
FIGURE 5.8 Kathryn Loukas encourages a client while she bravely takes on a chal- lenge in swimming
• Expressing worry, anxiety, or fear about the task or activity
• Becoming easily demoralized or self-doubting • Withdrawing or shutting down emotionally
• Giving up before the activity or shortly after beginning it • Avoiding therapy tasks or activities altogether
• Underestimating performance capacity (e.g., saying “I can’t do it”)
• Becoming easily irritated or angry
• Challenging the therapist when presented with an activ- ity or task
If such difficulties with change are not acknowledged and addressed, they are likely to be repeated and interfere with progress in therapy.
Affect
Clients’ affect not only reveals information about their thoughts and feelings, it influences the thoughts and emo- tions experienced by the therapist in reaction to the client (Fig. 5.9).
Clients vary in terms of the degree to which they express emotion during therapy. Some clients express their
feelings more freely, frequently, or intensely than others. High emotionality may be accompanied by periods of emotional numbness or void. Clients who vacillate between extremes of high intensity and low intensity may be having difficulty regulating or controlling their emo- tional states. Emotion regulation difficulties may reflect natural reactions to acute crisis situations. However if these difficulties are chronic, they suggest the presence of a mood disorder (e.g., bipolar disorder), a neurological disorder (e.g., traumatic brain injury), side effects of med- ications or other substances (e.g., alcohol intoxication), or a personality disorder (e.g., borderline personality disor- der). Any of the following behaviors may indicate that a client is having emotion regulation difficulties.
• Exhibiting a wide range of intense emotions within a short period of time (e.g., ranging from showing devas- tation and tears to gregariousness and laughter within a matter of minutes)
• Exhibiting behavioral impulsivity or poor judgment • Having difficulty controlling emotional reactions (e.g.,
inconsolable sobbing or uncontrolled rage)
If a client’s emotion regulation difficulties are chronic and remain unaddressed, they eventually disrupt the process of therapy.
Emotion regulation difficulties are not the only affec- tive issues that can challenge the therapeutic relationship. There are other clients who fail to show an appropriate level of emotion during therapy and appear chronically emotionally numb or void. When circumstances arise that would otherwise prompt an emotional reaction in a person, such clients may appear stoical, displaying constricted or blunted affect. There are a number of potential explana- tions for a client’s absence of emotion. They include, but are not limited to, a neurological condition (e.g., stroke), a developmental disorder (e.g., autism), a psychiatric disor- der (e.g., melancholic depression or negative symptoms of schizophrenia), or a personality disorder (e.g., avoidant or schizoid personality disorder).
In other cases, absence of emotion may be a natural aspect of a client’s personality, coping style, and/or cul- tural identity. Whatever the explanation for a person’s absence of affect, it is important that its source be recog- nized so the therapist does not personalize or misinterpret it in such a way that could have negative implications for the therapeutic relationship.
Another circumstance in which a client’s affect can influence the therapeutic relationship is when a client demonstrates an inappropriate emotional response to a given situation. For example, the client may laugh inap- Chapter 5 Knowing Our Clients: Understanding Interpersonal Characteristics 107
FIGURE 5.9 Clients vary in the extent to which they express emotion during therapy
propriately during group therapy when another client is discussing something painful or serious. Another example is a client who bursts into tears for no apparent reason or suddenly becomes nervous or agitated. In many cases, inappropriate affect suggests that a client may be uncom- fortable or anxious and may not know how to respond. However, when a client’s inappropriate affect seems unre- lated to stress or social discomfort, it may indicate that a client is responding to internal stimuli or experiencing a psychotic process.
When a client’s emotional reactions are consistent with the external events in his or her life or match the interpersonal circumstances occurring within the therapeu- tic relationship, they typically enhance communication, natural relating, and understanding between client and therapist. However, clients who differ from therapists in the way they convey emotion may at first seem overwhelming to therapists, particularly if the therapists lack experience managing diverse emotional reactions and styles or if they themselves have difficulty managing their own emotional reactions. Because emotional styles are deeply embedded aspects of psychological functioning, therapists must make an earnest attempt to truly understand the client from an empathic perspective. Such effort also helps the therapist attenuate any personal reactions to the client’s affect. As therapists attempt to understand their clients’ emotional reactions (or lack thereof), they maximize the likelihood that the clients themselves will achieve more self-understanding of their own reactions. Information on managing emotional inten- sity as it relates to sadness, anger, and anxiety is provided in Chapter 9.