Occupational and Physical Therapists’ Use of Intrapersonal and Interpersonal Emotion Regulation Strategies During Patient Interactions: A Qualitative Study

Study Design and Procedure

This was an exploratory qualitative study that used a constructivist epistemology, meaning that the knowledge we sought is perspectival (King & Brooks, 2017). It was approved by the local institutional review board. The research was conducted in two stages. In Stage 1, we conducted semistructured interviews with patients and therapists. We asked them to tell the story of a therapeutic relationship they had recently experienced or were currently experiencing and, in doing so, to highlight emotional events that occurred, the resulting emotions, and the emotion regulation strategies they used to address those emotions. Using semistructured interviews in Stage 1 data collection was beneficial because it enabled us to quickly access participants’ perceptions and include a wide range of therapy specialties. Stage 1 of data collection informed Stage 2 in that we developed a fine-tuned thematic template and interview schedule, both of which were used in Stage 2.

In Stage 2, data gained from unstructured, nonparticipant observation of patient–therapist dyads during their interactions, and from semistructured participant verification interviews, with each dyadic partner interviewed individually at the end of the relationship, were used to examine the participants’ perceptions of how they had used emotion regulation strategies during therapy interactions. We used unstructured observation techniques because they are an ideal way to collect rich data on behavior and interpersonal interaction under natural circumstances (Kelley, 2002; Mulhall, 2003), and they enable researchers to get an insider’s perspective of the relationship (Salmon, 2015). Ayana Horton, an occupational therapist with extensive experience working within therapeutic relationships, observed each dyad during their treatment sessions, from the first session, when they initially met, to the last, when the patient was discharged from therapy services. Therefore, the number of treatment sessions observed varied for each dyad, but it ranged from two to nine. The observations were done in person, with the observer seated in the clinic within hearing distance of the dyad being observed. An audio recorder was used to record dialogue. The observer was specifically looking to witness events that may cause emotion and note how each dyadic partner responded to those events. The data collected through observation were not analyzed; they were used only to inform the participant verification interviews.

The purpose of the participant verification interviews was to verify our impressions of emotional events, the resulting emotions, and the emotion regulation strategies used with the participants’ point of view. The interview schedule from Stage 1 was used in the participant verification interviews; however, for each dyad the interview was heavily augmented with questions and prompts informed by the data collected through observation. In this way, we could ask informed questions about interactional dynamics that occurred during the therapeutic relationship and verify our understanding with the participants’ perceptions. For example, if, through observation of dyadic interactions, it appeared that a particular emotion regulation strategy was used, Horton would ask both dyadic partners about it during the interview.

Stage 2 of this study built on Stage 1 by using methodological triangulation and including dyadic partners in therapeutic relationships. Interviews and dialogue during treatment sessions were audio recorded and transcribed. All data were collected by Horton.

Several strategies were used to ensure the trustworthiness of this research. We used methodological triangulation to cross-verify the data collected and pilot studies to fine-tune the data collection process. We also used member checking to ensure that our understanding was in line with the participants’ understanding. A reflective journal was also used to record assumptions, actions, and rationales for those actions.

Participants

Participants were recruited using purposive sampling from three hospitals and one clinic in the United Kingdom. In Stage 1, 9 physical therapists and 13 occupational therapists (19 female, 3 male) participated. The therapists ranged in age from their 20s to their 60s. They worked in various specialty areas, such as musculoskeletal, accident and emergency, and neurology. They ranged in years of experience from 1 yr to 35 yr.

In Stage 2, 14 dyads were recruited from hand therapy clinics in London. The therapists ranged in age from their 20s to their 40s and had between 2 and 20 yr of experience. Three of the therapists were physical therapists, and the remaining 5 were occupational therapists (7 female, 1 male). Participants in Stage 1 did not participate in Stage 2, and vice versa. Some of the 8 participated in more than one dyad.

Data Analysis

We analyzed the data using template analysis, as described by King (2004a), and NVivo (Version 10). The data analysis began with the formulation of an initial template that consisted of codes based on prior research. Relevant sections of each transcript were coded using King’s (2004a, 2004b) description of the process as a guide. As thematic codes emerged from the data, we incorporated them into the template. In this way, we added, deleted, and fine-tuned the thematic codes on the template until it was an accurate representation of the themes emanating from the data (King, 2004a, 2004b).

The data were collected and analyzed simultaneously, and data analysis was conducted in repetitive cycles. Each cycle of data collection and analysis benefited from an increasingly fine-tuned template and our increasing level of familiarity with the data. Because the data from both stages of data collection focused on understanding therapists’ use of emotion regulation strategies, they are reported together. Only the data relevant to therapists’ use of emotion regulation strategies are reported in this article.

How Therapists Used Intrapersonal Emotion Regulation in Response to Negative Emotion

Therapists described using all categories of intrapersonal emotion regulation strategies described in the Process Model of Emotion Regulation to regulate their own negative emotions (Table 1). Situation selection strategies involve choosing to engage or not engage in situations to promote desired emotions and avoid undesired emotions (Gross, 1998). The main way that therapists used situation selection in therapeutic relationships was by avoiding interacting with patients who provoked negative emotions. Therapists can do this by exchanging patients with another therapist or a therapy student. As one occupational therapist, in her 20s and with 6 yr of experience, shared, “Me and the [physical therapists] split them up, and she’ll go one day, and I’ll go another. And we’ve got a student, so we send the student the other day. So, it spreads the load a little bit.”

Situation modification strategies are used to change a situation so one can experience desired emotions (Gross, 1998). In this study, therapists used situation modification strategies to steer their interactions in such a way as to avoid negative emotions. This often involved efforts to prepare themselves practically and emotionally. For example, one therapist explained how she prepared herself before working with a patient to avoid feeling the anxiety and embarrassment associated with appearing nervous or incompetent:

Prepared myself before going in. . . . You know how you kind of psych yourself up? You really think through what your treatment plan’s going to be, think through what you’re going to say just in case the family comes and it’s the whole deep breath, in you go. (physical therapist, 13 yr of experience, 30s)

In preparing for sessions, this therapist modified the situation from one in which she could have been ill prepared to one in which she appeared competent. In the quote, she mentions that she would psych herself up. This can be understood as providing evidence that she was simultaneously using cognitive reappraisal strategies, which are intended to modify how one appraises a situation so as to facilitate the desired emotions (Gross, 1998), to prepare for the treatment sessions.

Other therapists also described using cognitive reappraisal to protect themselves, to maintain their professionalism, to be able to get their job done, and to feel better. They tended to use cognitive reappraisal to not take personally a patient’s or family’s negative behaviors toward them or to remind themselves of the limits of their responsibility. One occupational therapist (35 yr of experience, 60s) described how she used cognitive reappraisal to cope with the despair she felt when one of her patients died 1 wk after he was discharged to home by thinking about the positive aspects of the situation: “I felt . . . he’s gone to rest; the suffering has gone . . . he’s had good care . . . the best that we could offer . . . and so that gives me that satisfaction.”

Therapists also used cognitive reappraisal to give themselves permission to feel negative emotions, albeit in a controlled way. A physical therapist with 3 yr of experience and in her 20s reported, “Actually, sometimes unfortunately, like, you can only do what you can do. And so, you have to sometimes, it sounds bad, but be at peace with that.”

Attentional deployment strategies are those that attempt to direct or redirect one’s attention to influence one’s own emotional experience (Gross, 1998). One of the primary ways therapists used attentional deployment was by ignoring negative emotional events, such as a patient’s display of anger or irritation directed toward them: “I guess I just blocked it out after I knew that I couldn’t change the outcome” (physical therapist, 4 yr of experience, 20s).

Over time, some therapists became acclimated to the common affective events that provoke negative emotion, and thus the emotional significance of these events decreased: “Certain frustrations now bounce off my back because I can’t influence them. . . . What’s the point in worrying about things I can’t influence?” (occupational therapist, 6 yr of experience, 20s). This statement can be understood as an example of a therapist using attentional deployment and cognitive reappraisal at the same time. The therapist described her need to let frustrations bounce off her back. This is an indication of an attentional deployment strategy, and questioning the point of worrying about things one cannot influence is an indication of cognitive reappraisal.

Response-focused strategies focus on influencing the experiential, physiological, or behavioral components of an emotional response (Gross, 1998). Examples of a therapist’s use of such strategies include hiding their frustration, holding back tears, and taking a deep breath to try to manage anxiety. According to one physical therapist (13 yr of experience, 20s), “It’s keeping that professional face and then going away to the bathroom and having a good cry. So yes, the emotions do come out, but hopefully not in front of a patient.” Another (occupational therapist, 7 yr of experience, 30s) shared, “So, if I’d got really angry with them, that wouldn’t have achieved anything. So, I was internally frustrated. But I didn’t let that out.”

Hochschild (1983) called these strategies surface acting. Therapists used these strategies to maintain their professional composure and deescalate tense situations. In addition to using intrapersonal emotion regulation strategies before and during therapy encounters, therapists also used them after the encounters. For example, after a stressful encounter, therapists may use strategies such as venting, “switching off,” crying, seeking support, eating, and exercising to address residual emotions. One occupational therapist, in her 60s and with 40 years of experience, said, “I said to my manager that I bent over backward to help this family and this is what I get?” Another occupational therapist (6 yr of experience, 20s) shared, “If I’m feeling a bit rotten then I’ll have a big bag of crisps. And that works. And that [works] at work as well. ‘It’s been a bad day—shall we go out for lunch?’ It’s quite a common thing in our office.” A third occupational therapist (3 yr of experience, 30s) said, “I exercise because of work, I think, more than anything else and probably at times have a glass of wine.”

Situation selection and modification are proactive (or antecedent-focused) intrapersonal emotion regulation strategies because they are used before emotion is experienced. Attentional deployment, cognitive reappraisal, and response modulation are reactive (or response-focused) intrapersonal emotion regulation strategies because they are used after the experience of emotion.

How Therapists Use Interpersonal Emotion Regulation Strategies

Therapists reported that regulating their patients’ emotions is an essential part of their job. In fact, at times, regulating their patients’ emotions took priority over therapeutic interventions because the patients’ emotions influenced their ability to take part in therapy: “Even though I was going to see her as a [physical therapist], we didn’t necessarily do any [physical therapy] sessions. It was more [of us talking] and let[ting] her deal with her emotions. And then next time we come and do the [physical therapy] session” (physical therapist, 13 yr of experience, 30s).

Therapists described using a wide range of strategies that can be categorized according to Williams’s (2007) interpersonal emotion management framework (Table 2). Altering the situation involves modifying or changing the situation to influence the emotional impact on the target (Williams, 2007). Therapists used this type of strategy proactively—that is, in anticipation of emotion rather than in response to emotion— to avoid negative emotions. For example, therapists stated that at times they told their patients they might not achieve full recovery as a tactic to manage the patient’s expectations and avoid patients experiencing negative emotions if they subsequently did not fully recover. “I think it is important to manage patients’ expectations so they can be more realistic regarding what they think they will get out of therapy” (occupational therapist, 7 yr of experience, 30s).

One occupational therapist (2 yr of experience, 20s) discussed how she tells her patients up front that certain decisions are not up to her, even though that is not true, as a way to avoid patient anger if she makes a decision with which the patient disagrees: “It just makes it easier for me . . . because I don’t want to deal with [patients’ anger].”

Altering-attention strategies are used to divert the target’s attention to influence their emotions (Williams, 2007). Therapists in our study reported using small talk to take patients’ minds off taxing or painful therapy. They redirected their patients’ attention away from stimuli that could cause negative emotions, such as the patients’ uncertain future functional status or a decline in functional status. One therapist (6 yr of experience, 40s) explained that although she allows her patients to express their worries, she tries to prevent them from ruminating on those worries by refocusing the patient on the task at hand: “If [the patient is] tearful, I listen. I’ll be respectful and understanding, but then I’ll move on. ‘That’s okay, that’s that, so how can we move on?’”

Similarly, another therapist explained how she used the therapy as an attention-altering strategy:

I just reassured him and said ‘These things happen. . . . Try not to focus on it and be too hard on yourself because lots of people have been in the same situation.’ And those sorts of things. So, and then just focusing on the getting him up and doing more active things to take his mind off it and feel like he is achieving. (physical therapist, 8 yr of experience, 30s)

This is an example of a therapist using two types of interpersonal emotion regulation strategies at the same time. When the therapist told the patient that many people have been in the same situation, she was also trying to help the patient to understand that he is not alone. This strategy can be categorized as altering the cognitive meaning of a situation, which is helping the target think about an issue differently in an attempt to change the emotional consequences. Strategies of altering the cognitive meaning of a situation are often used when patients are feeling sad about their lack of functional independence; they are a way to help patients to see the bright side of things. Another example of therapists’ use of this strategy is when a therapist encourages a patient to think about incremental improvements they have made instead of dwelling on how far they are from their rehabilitation goals.

Modulating the emotional response involves actions used to change the target’s current experience or expression of emotion (Williams, 2007). In general, therapists in our study believed that patients had the right to feel negative emotions. For this reason, they did not try to encourage patients to suppress negative emotions unless the emotions were particularly intense and directed at the therapist. One physical therapist (8 yr of experience, 30s) described how she attempted to regulate her patient’s emotional expressions by setting and enforcing boundaries regarding which emotional expressions were appropriate and which were not. Patients’ emotional expressions that fell outside of those boundaries drew undesirable consequences:

I think a large part of it was building boundaries and then letting him [the patient] know where the boundaries lie in terms of what he could and couldn’t do [talking about the patient’s emotional expression] . . . So, you’re saying, I’m not going to accept it. If you’re going to shout, then I’ll come back when you’ve calmed down.

Altering the situation is a proactive interpersonal emotion regulation strategy in that it is enacted in anticipation of another person’s emotion. Altering attention, altering meaning, and modulating the emotional response are reactive interpersonal emotion regulation strategies in that they are used in response to another person’s emotion.