Abstract
Introduction
Emotion regulation may be an important tool that therapists and patients use to build and maintain therapeutic relationships. This exploratory study investigates how patients use intrapersonal and interpersonal emotion regulation strategies during interactions with occupational therapists and physiotherapists.
Methods
A two-staged qualitative study was conducted. In the first stage 11 patients were interviewed regarding their use of emotion regulation during their therapeutic relationships. In the second stage, 14 patient/therapist dyads were observed during the course of the therapeutic relationship and then interviewed individually at the end of the relationship.
Results
Patients utilise the full range of intrapersonal emotion regulation strategies that can be categorised in Gross’s (1998) process model of emotion regulation including situation selection, situation modification, attentional deployment, cognitive reappraisal and response modulation. They used interpersonal emotion regulation strategies to a lesser extent, only reporting using strategies that fit into one of the four interpersonal emotion regulation strategies identified Williams’ (2007), altering the situation.
Conclusions
This study makes an important contribution to research on patients’ contribution to therapeutic relationship development/maintenance. It is the first study to explore patients use of intrapersonal and interpersonal emotion regulation in response to negative and positive emotions arising from interactions with therapists.
Keywords: emotion regulation, therapeutic relationships, occupational therapy, physiotherapy
Introduction
The therapeutic relationship refers to the interpersonal relationship between the healthcare professional and patient (Peplau, 1997). Since emotions influence how we understand the quality of relationships (Methot et al., 2017) and play a significant role in deciding the trajectory of interpersonal relationships (Berscheild, 1983) emotion regulation may be an important tool that healthcare professionals and patients use both consciously and unconsciously to build and maintain therapeutic relationships. Emotion regulation is the goal-directed process of regulating the occurrence, magnitude or duration of emotional responses (Gross et al., 2011). The regulation of one’s own emotional responses is called intrapersonal emotion regulation. The regulation of other’s emotions is called interpersonal emotion regulation (Gross, 2015).
People use a wide variety of intrapersonal and interpersonal emotion regulation strategies. The most widely used classification of intrapersonal emotion regulation strategies is Gross’s (1998) process model of emotion regulation. It categorises five families of intrapersonal emotion regulation strategies identified by the point in the emotion-generative process where they are used. Emotion regulation strategies that are used prior to the emotion being generated are called antecedent-focused emotion regulation. Situation selection, situation modification, attentional deployment and cognitive change or reappraisal are all antecedent-focused emotion regulation strategy families. Situation selection is taking actions to ensure that one will be in a situation that promotes the desired emotions. Situation modification is taking actions to change a situation in order to promote desired emotions. Attentional deployment refers to directing one’s attention to influence one’s emotional response. Cognitive change refers to modifying how one appraises a situation in order to promote the desired emotional response (Gross, 1998).
Emotion regulation strategies that are used after the emotion is generated are called response-focused emotion regulation. Response modulation is the only category of response-focused emotion regulation strategies (Gross, 1998). Response modulation refers to strategies that directly influence the experiential, behavioural or physiological components of the emotional response (Gross, 1998).
Williams (2007) identified four categories of interpersonal emotion regulation strategies based upon Gross’s (1998) families of intrapersonal emotion regulation strategies. The four categories are altering the situation, altering attention, altering the cognitive meaning of a situation, and modulating the emotional response. Altering the situation is modifying or changing the situation to influence the emotional impact on another person. Altering attention are strategies used to divert another person’s attention to influence their emotions. Modulating the emotional response are actions used to alter a person’s current experience or expression of emotion. Altering the cognitive meaning of a situation are strategies used to help another person think differently about an issue to alter the emotional impact (Williams, 2007). See Table 1 for emotional regulation strategies described by Williams (2007) and Gross (1998).
Table 1.
Intrapersonal and interpersonal emotion regulation strategies.
| Intrapersonal emotion regulation strategies (Gross, 1998) | |
|---|---|
| Cognitive change | Strategies used to modify how one appraises a situation in order to promote the desired emotional response |
| Attentional deployment | Strategies focused on directing one’s attention to influence one’s own emotional response |
| Situation modification | Strategies focused on taking actions to change a situation in order to promote emotions that are desired |
| Situation selection | Strategies used to ensure that one will be in a situation that promotes the desired emotions |
| Response modulation | Strategies used to directly influence the experiential, behavioural or physiological components of an emotional response |
| Interpersonal emotion regulation strategies (Williams, 2007) | |
| Altering the situation | Strategies used to modify or change the situation to influence the emotional impact on another person |
| Altering attention | Strategies used to divert another person’s attention to influence their emotions |
| Altering the cognitive meaning | Strategies used to help another person think differently about an issue to alter the emotional impact |
| Modulating the emotional response | Strategies used to alter a person’s current experience or expression of emotion |
Literature Review
Research on emotion regulation in healthcare contexts is mostly focused on the emotion regulation strategies that healthcare professionals use (i.e. Barnett et al., 2020; Ruiz-Aranda et al., 2021). Since emotion regulation is a reciprocal dyadic process, where the actions and behaviours of one dyadic partner influences the actions and behaviours of the other dyadic partner (Côté, 2005), we cannot fully understand emotion regulatory processes within therapeutic relationships without understanding the role that patients play in this process.
Research on patients’ use of intrapersonal emotion regulation is mostly focused on how their use of these strategies is associated with their symptoms and recovery (i.e. Aldao et al., 2014; Karademas et al., 2020), and how emotion regulatory training effects their emotion recognition and expression abilities (Cho and Jang, 2019). This research does not consider emotion regulation in the context of therapeutic relationships.
There is a lack of research that specifically focuses on patients’ use of interpersonal emotion regulation strategies during interactions with healthcare professionals. A recent study that is relevant to this topic explored how patients’ emotions influenced therapists’ emotions and vice versa (Soma et al., 2020). However, this study did not look at specific emotion regulatory strategies that patients or therapists used. Another related area of research focused on strategies that patients use to influence how their therapists feel about them.
For example, Hockey (1986) conducted an observational study and found that patients used strategies, such as making efforts to appear good-natured and caring, to make themselves more acceptable to the care staff. Also, when they required assistance, they would approach the nurses cautiously and politely. Another study found that patients would praise nurses for their efforts to present themselves as nice people and put on a brave face to mask their own suffering (Copp, 1996). Although these studies do not discuss interpersonal emotion regulation, they highlight that patients try to influence how their healthcare professionals feel and think of them.
Patients who use emotion regulation strategies effectively may be able to build better therapeutic relationships. Given the importance of therapeutic relationships to patient outcomes (Hall et al., 2010; Alodaibi et al., 2021) and patient satisfaction (Beattie et al., 2002), it is vital to understand patients’ role in therapeutic relationship development and maintenance. To address this gap in the knowledge base, qualitative methods were used to understand how patients use emotion regulation strategies during interactions with therapists.
Method
Study design and procedure
This research was done as part of the first author’s doctoral research and it was approved by the local ethics institutional review board and the National Health Service. This exploratory qualitative study uses a constructivist epistemology and was conducted in two stages. In the first stage semi-structured interviews were used with therapists and patients, individually. They were asked to tell the story of a therapeutic relationship that they recently experienced and in doing so, highlight the significant emotional events that occurred during the relationship. Emotional events are happenings to which people respond emotionally (Weiss and Cropanzano, 1996). In relation to each emotional event, they were asked to identify the resulting emotions and the emotion regulation strategies they used to address the emotions.
In the second stage unstructured, non-participant observation of patient/therapist dyads and participant verification interviews were used. The dyads were observed during their interactions throughout the duration of their therapeutic relationships. The participant verification interviews were conducted with the therapist and patient, individually, at the end of the relationship. Unstructured observation was used because it is an ideal way to collect rich data on behaviour and interpersonal interaction under the most natural circumstances (Mulhall, 2003; Kelley, 2002) and enables the researchers to get an insider’s perspective (Salmon, 2015). The observations were used to inform the participant verification interview schedules so that the interviewer could ask questions specific to each dyads interactions and compensate for any potential bias caused by omitted information due to participant’s lack of memory or appreciation of relevance. The participant verification interviews were used to access participants perceptions of emotional events, resulting emotions and emotion regulation strategies. This form of methodological triangulation was used to strengthen trustworthiness of the study. Interviews and dialogue during treatment sessions were audio recorded and transcribed. Only the data relevant to the patients’ use of emotion regulation strategies is reported in this paper. All data collection was conducted by the first author in consultation with the second and third author. The first author is an occupational therapist with extensive experience of working within therapeutic relationships.
Participants, recruitment and context
Participants were recruited using purposive sampling from three hospitals and one clinic in the United Kingdom. In the first stage, 11 patients participated; six of whom were female and five were male. The sample ranged in age from those in their 20s to older participants in their 60s (see Table 2). In the second stage six dyads (six patients and two therapists) were recruited for the pilot study and eight dyads (eight patients and eight therapists) were recruited for the main study (see Table 3). They were recruited from hand therapy clinics in London. The patients ranged in age from their 20s to their 60s.
Table 2.
Demographics of participants demographics in stage 1.
| Main study pseudonyms for patients | Occupation | Service | Age | Gender M - male F - female |
|---|---|---|---|---|
| 1-1-P | Retired | Physiotherapy | 60 | M |
| 1-2-P | Sales manager | Physiotherapy | 40 | F |
| 1-3-P | Psychotherapist | Occupational therapy | 60 | F |
| 1-4-P | Retired | Physiotherapy | 60 | M |
| 1-5-P | Pension analyst | Physiotherapy | 40 | M |
| 1-6-P | Receptionist | Physiotherapy | 40 | F |
| 1-7-P | Lecturer | Occupational therapy | 50 | F |
| 1-8-P | Retail | Physiotherapy | 20 | F |
| 1-9-P | Unknown | Occupational therapy | 40 | M |
| 1–10-P | Professor | Occupational therapy | 60 | M |
| 1–11-P | Retired | Occupational therapy | 50 | M |
Table 3.
Demographics of participants in stage 2.
| Study 2 pilot | Occupation | Years of experience | Age | Gender M - male F - female | Pseudonym |
|---|---|---|---|---|---|
| Dyad 1A - Therapist | Occupational therapist | 2 | 30 | M | S2P-1-T |
| Dyad 1A - Patient | Retired | Not applicable | 60 | F | S2P-1A-P |
| Dyad 1B - Therapist | Occupational therapist | 2 | 30 | M | S2P-1-T |
| Dyad 1B - Patient | Lecturer | Not applicable | 50 | F | S2P-1B-P |
| Dyad 1C - Therapist | Occupational therapist | 2 | 30 | M | S2P-1-T |
| Dyad 1C - Patient | AV worker | Not applicable | 30 | M | S2P-1C-P |
| Dyad 2A - Therapist | Occupational therapist | 20 | 40 | F | S2P-2-T |
| Dyad 2A - Patient | Housewife | Not applicable | 50 | F | S2P-2A-P |
| Dyad 2B - Therapist | Occupational therapist | 20 | 40 | F | S2P-2-T |
| Dyad 2B - Patient | Unemployed | Not applicable | 50 | F | S2P-2B-P |
| Dyad 2C - Therapist | Occupational therapist | 20 | 40 | F | S2P-2-T |
| Dyad 2C - patient | Unemployed | Not applicable | 50 | F | S2P-2C-P |
| Study 2 | Occupation | Years of experience | Age |
Gender M – male F - female |
Pseudonym |
| Dyad 1 - Therapist | Occupational therapist | 7 | 40 | M | 2-1-T |
| Dyad 1 – Patient | Unemployed | Not applicable | 50 | M | 2-1-P |
| Dyad 2 - Therapist | Occupational therapist | 5 | 30 | F | 2-2-T |
| Dyad 2 – Patient | Housewife | Not applicable | 60 | F | 2-2-P |
| Dyad 3 - Therapist | Occupational therapist | 3 | 20 | F | 2-3-T |
| Dyad 3 – Patient | Cleaner | Not applicable | 60 | F | 2-3-P |
| Dyad 4 - Therapist | Occupational therapist | 2 | 30 | F | 2-4-T |
| Dyad 4 – Patient | Courier | Not applicable | 20 | M | 2-4-P |
| Dyad 5 - Therapist | Occupational therapist | 15 | 30 | F | 2-5-T |
| Dyad 5 – Patient | Retired | Not applicable | 60 | M | 2-5-P |
| Dyad 6 - Therapist | Physiotherapist | 3 | 20 | F | 2-6-T |
| Dyad 6 – Patient | Airforce | Not applicable | 50 | M | 2-6-P |
| Dyad 7 - Therapist | Physiotherapist | 6 | 30 | F | 2-7-T |
| Dyad 7 – Patient | Teaching assistant | Not applicable | 50 | F | 2-7-P |
| Dyad 8 - Therapist | Occupational therapist | 5 | 30 | F | 2-8-T |
| Dyad 8 – Patient | Student | Not applicable | 20 | M | 2-8-P |
Data Analysis
The data were analysed using template analysis as described by King (2004) and NVivo 10 software package. This data analysis method was used because it enables to researcher to utilise pre-existing conceptualisations in the initial template and then use the data to develop and transform it. The data analysis began with the formulation of an initial template which consisted of codes based on prior research, specifically Gross’s (1998) families of intrapersonal emotion regulation strategies and Williams’ (2007) families of interpersonal emotion regulation. Relevant sections of each transcript were coded and the codes were incorporated into the template. The researcher added, deleted and fine-tuned the thematic codes on the template until it was an accurate representation of themes emanating from the data. The data were collected and analysed simultaneously and in repetitive cycles.
Findings
Patients experience a wide range of negative and positive emotions when working with therapists. Positive emotions refer to those emotions are that desirable and pleasant. Negative emotions refer to those emotions that are undesirable and unpleasant. The term ‘negative’ does not indicate that these emotions are not useful or adaptive. Patients described how they used intrapersonal and interpersonal emotion regulation strategies to regulate positive and negative emotions.
Patients’ use of intrapersonal emotion regulation strategies in response to negative emotions
Patients experienced negative emotions such as anger, fear and anxiety. In response to negative emotions, patients used a wide range of intrapersonal emotion regulation strategies that fall into each family of intrapersonal emotion regulation strategies categorised by Gross (1998) (see Table 4). Patients discussed hypothetical or contemplated use of situation selection strategies, that would result in the discontinuation of the therapeutic relationship. Situation selection strategies are actions to ensure that one will be in a situation that promotes the desired emotions (Gross, 1998). For example, when discussing an emotional event where a patient was expressing her anger to a therapist, the patient remarked:
“…clearly when I was being angry with her, if she turned around and was angry with me, I would have walked out and put in a complaint.”
(1-7-P) Occupational therapy patient, profession – lecturer, age range – 50s
Table 4.
Emotion regulation strategies used by patients.
| Intrapersonal emotion regulation strategies | |
|---|---|
| Emotion regulation strategies | Examples of Patient’s use of emotion regulation strategies |
| Situation selection – Strategies used to ensure that one will be in a situation that promotes the desired emotions (Gross, 1998) | ‘…clearly when I was being angry with her if she turned around and was angry with me I would have walked out and put in a complaint’. (1-7-P) Occupational therapy patient, profession – lecturer, age range – 50s |
| Situation modification – Strategies focused on taking actions to change a situation in order to promote emotions that are desired (Gross, 1998) | ‘Maybe the reason I said that (referring to asking for the alternative treatment approach) was to indicate, oh, if you keep up the ultrasound then you won’t necessarily have to manipulate my arm and give me pain’. (1-3-P) Occupational therapy patient, profession – psychotherapist, age range – 60s |
| Attentional deployment – Strategies focused on directing one’s attention to influence one’s own emotional response (Gross, 1998) | ‘Breathe. I use breathing exercises. So, and trying to relax. Intentionally relaxing because I know for a fact that if you relax it helps the person treating you and it also helps you. It would help me’. (1-3-P) Occupational therapy patient, profession – psychotherapist, age range – 60s |
| Cognitive change – Strategies used to modify how one appraises a situation in order to promote the desired emotional response (Gross, 1998) | ‘…I know that he (the therapist) can’t work miracles so I supposed in my mind…I wouldn’t have expected masses of differences in the early stages. So, I suppose within my mind I was quite realistic about, or I wasn’t unrealistic in what I expected’. (1-8-P) Physiotherapy patient, profession – retail, age range – 20s |
| Interpersonal emotion regulation strategies | |
| Altering the situation –Modifying or changing the situation to influence the emotional impact on the target (Williams, 2007) | ‘I had to do a lot of, sort of like, thinking about the actual, how I was going to fit the exercises around my daily routine… and to kind of kick my butt to make sure that I did them. So that I wouldn’t feel like I’d let him down by not keeping up with them and doing them as he’d told me to do them’. |
Situation modification is taking actions to change a situation in order to promote desired emotions (Gross, 1998). The main situation modification strategies that patients used were asking questions and trying to solve the problem. When patients first started treatment, they often asked questions to avoid or alleviate anxiety stemming from not knowing what to expect. Asking questions enabled them to change the situation into one where they have a more comfortable grasp on the treatment regimen.
“I just talked to him (the therapist) and asked questions and the nervousness went away.”
(1-5-P) Physiotherapy patient, profession – pensions analyst, age range – 40s
Attention deployment strategies are strategies to direct one’s attention to influence one’s emotional response (Gross, 1998). Patients reported using these strategies to avoid or ignore unwanted negative emotions. Some patients focused on something particular like their breathing, and other patients just avoided focussing on the problem.
“I just tried to ride the anxiety out… distract myself”
(1-8-P) Physiotherapy patient, profession – retail, age range – 20s
“I use breathing exercises... intentionally relaxing because I know for a fact that if you relax it helps the person treating you and it also helps you.”
(1-3-P) Occupational therapy patient, profession – psychotherapist, age range – 60s
Patients used cognitive reappraisal strategies to address unwanted negative emotions that arise when working with their therapist. Cognitive reappraisal strategies are those focused on modifying how one appraises a situation in order to promote the desired emotional response (Gross, 1998). They used these strategies to talk themselves down so that they resist acting on maladaptive response tendencies, such as angry outbursts that would have a negative effect on their relationship with their therapist. They also used cognitive reappraisal to perceive their therapist as competent in order to alleviate their anxiety regarding participating in therapy.
“I thought to myself, give him a chance, he’s doing his job, he is a professional.”
(1-1-P) Physiotherapy patient, profession – retired, age range – 60s
In addition, they used cognitive reappraisal to manage their emotions in situations where they did not make as much progress as they would have liked.
“…I know that he (the therapist) can’t work miracles so I supposed in my mind…I wouldn’t have expected masses of differences in the early stages.”
(1-8-P) Physiotherapy patient, profession – retail, age range – 20s
Patients reported using response modulation, strategies that directly influence the experiential, behavioural or physiological components of the emotional response (Gross, 1998). For example, a patient who was angry because of the pain he experienced during therapy, described thinking about expressing his anger violently towards the therapist but instead suppressed and postponed his expression of anger to a more acceptable time.
“I wanted to punch him… when he was hurting me… and I used to go out when I’d finished and go outside into the road and kick a tree or something…Something to take away the frustration out on something.”
(1-1-P) Physiotherapy patient, profession – retired, age range – 60s
Although patients used strategies to modify the emotions they experienced, patients believed they had the right to feel the way they truly felt. For this reason, they often showed their true emotion even if it was negative. One patient discussed how she expressed her anger towards her therapist after she was invited to attend the therapy session at the wrong time.
“I just said, this is wasting my whole day from work, you know. Why can’t you get it right!”
(1-7-P) Occupational therapy patient, profession – lecturer, age range – 50s
Another patient discussed how she expressed her sadness, stemming from the recent death of a close family member, when she came to treatment.
“So, I think I actually just went in there and blurted it all out. I didn’t cry but I was feeling very emotional.”
(1-2-P) Physiotherapy patient, profession – sales manager, age range – 40s
However, this entitlement was not without boundaries as many patients thought that if they expressed extreme negative emotions, such as rage, it would have a negative impact on their therapeutic relationship and their rehabilitation.
“Yes extreme (emotions)…I don’t believe sort of when you’re receiving treatment from someone that you should display those emotions…those (extreme emotions) are bad and that can have an impact on how that person perceives you and how you’re treated as well.”
(1-8-P) Physiotherapy patient, profession – retail, age range – 20s
Patients’ use of intrapersonal emotion regulation strategies in response to positive emotions
In general, patients deemed their felt experience of positive emotions as desirable, and therefore, they often did not feel the need to regulate the expression of these emotions. Instead they expressed them naturally. However, patients reported using one intrapersonal emotion regulation strategy, attentional deployment, to amplify the positive emotions that they felt since these emotions were desirable and enjoyable. For example, a patient described how she facilitated her experience of positive emotions using attentional deployment after the event.
“I don’t think I did anything (to regulation my emotions) other than just thinking about my progress and the pain changing. The pain improving. Although it’s still pain but it is changing and there is progress.”
(1-3-P) Occupational therapy patient, profession – psychotherapist, age range – 60s
Patients did not report using any strategies to decrease the experience of positive emotion. This may be because the strength of the positive emotion they experienced and/or the situation did not warrant such actions. However, in situations where the positive emotion is more intense, for example, a situation where a patient feels romantic love for his therapist, the patient may be more likely to try and decrease their experience of that emotion.
Patients’ use of interpersonal emotion regulation strategies
Patients did not use many interpersonal emotion regulation strategies (see Table 4). This may be because during patient/therapist interactions, therapists typically display emotions that fit into the confines of organisationally sanctioned emotional display rules. Another potential reason for this is patient generally did not think regulating their therapist’s emotions was their responsibility.
“…it’s just a very one-way (relationship), when you go to your doctor, you don’t think, I’m going to go there to manage your doctor’s emotion. And therapists fall into the same, they’re there to manage you, you know... I don’t think, ‘well I’m going to have to manage her emotion’. That’s not what I’m there for.”
(1-7-P) Occupational therapy patient, profession – lecturer, age range – 50s
However, patients did use interpersonal emotion regulation proactively, meaning in anticipation of emotion rather than in response to emotion. For example, patients mentioned they would give positive feedback and say, ‘thank you’ to their therapists as a way of sharing their positive emotions. Another example of patients’ proactive use of interpersonal emotion regulation is patients who said they would be sure to be compliant with the therapist’s home exercise recommendations to avoid the therapist being frustrated with them. One patient described how she had to be strict with herself to ensure she did her exercises regularly to avoid her therapist being disappointed.
“I had to do a lot of, sort of like, thinking about the actual, how I was going to fit the exercises around my daily routine… and to kind of kick my butt to make sure that I did them. So that I wouldn’t feel like I’d let him down by not keeping up with them and doing them as he’d told me to do them.”
(1-8-P) Physiotherapy patient, profession – retail, age range – 20s
These strategies fit into Williams’ (2007) category of interpersonal emotion regulation strategies, Altering the Situation. Altering the situation involves modifying or changing the situation to influence the emotional impact on the target (Williams, 2007).
Discussion
This study sought to understand how patients use emotion regulation strategies during their interactions with therapists. This is the first study to explore patients use of interpersonal and intrapersonal emotion regulation strategies used in response to positive and negative emotion within the context of therapeutic relationships and highlights the patients’ role in therapeutic relationship development and maintenance
Patients used a full range of intrapersonal emotion regulation strategies prior to, during and after interactions with therapists. While patients used interpersonal emotion regulation strategies, they did not use these strategies to the same extent. This was partially because they did not feel like it was their responsibility to do so. This finding is consistent with studies that have found that patients/clients viewed their therapists as primarily responsible for building positive therapeutic relationships (Bedi et al., 2005); (Bachelor, 1995). It was also partially because the therapists did not display emotions that the patients believed needed to be regulated. This finding is also consistent with studies that demonstrate the emotional display rules are widely recognised among healthcare professionals (Diefendorff et al., 2011).
Patients experience many positive and negative emotions when working with healthcare professionals. They use emotion regulation strategies to facilitate positive emotions and avoid negative emotions. Their tendency to use emotion regulation strategies in this way is adaptive since experiencing positive emotions can influence their experience of their health condition. Positive emotions and mood enhance personal resilience (Fredrickson, 2006) are associated with greater adherence to health behaviours (Duque et al., 2019) and decreased experience of pain (Strand et al., 2006).
Patients’ experience and expression of emotions, and their ability to regulate others’ emotions can also influences their experience of healthcare services. Positive emotions foster interpersonal connection (Fredrickson, 2000), which can help build therapeutic relationships. Patients experience and/or expression of positive emotion or positive mood is associated with being liked by healthcare professionals (Hall et al., 2002). However, a recent study demonstrated that a patients’ negative affect reduced male physicians liking significantly but had no influence on female physician liking (Gulbrandsen et al., 2020). Being liked by healthcare professionals is associated with higher patient satisfaction (Hall et al., 2002; Levinson et al., 2006), and predicted patient-centred behaviour in female physicians (Gulbrandsen et al., 2020). In contrast, patients who experience and display negative emotions may trigger service sabotage behaviours (Chi et al., 2013).
Practical Implications
The findings discussed in this study have practical implications for occupational therapists and physiotherapists. Patients experience a wide range of emotions prior to, during and after their encounters with therapists. For this reason, therapists should focus on addressing patients’ emotions not only during the treatment session but also before and after the treatment sessions. Prior to the encounters, patients mainly reported anxiety due to not knowing what to expect. Therapists may address this by sending an informational leaflet to patients prior to the first treatment session to inform them of what to expect. Alternatively, therapists could adapt a practice of contacting the patient via telephone prior to the first treatment session to provide information and therefore alleviate the patient’s anxiety. After the therapy session, patients, particularly those who experienced pain during the session, may experience negative emotions, such as anger and frustration. To address this, therapists could practice ensuring the treatment session ends in a way that empowers patients, where they have the opportunity to express their voices and frustrations and feel listened to. They could end the treatment session with something that is soothing like a therapeutic massage or with a task that the patient can do with little difficulty.
The findings also have practical implications for educational institutions and healthcare organisations that train and hire occupational therapists and physiotherapists. Given the important role of emotion regulation in building and maintaining the therapeutic relationships, healthcare organisations and educational institutions should support therapists in developing these skills. Therefore, training programs to help therapists learn to use intrapersonal and interpersonal emotion regulation during their interactions with patients are needed. Such programs may benefit from utilising role-playing exercises where therapists or student therapists can practice navigating various scenarios. Practicing addressing emotions in this way can enable therapists to improve their effectiveness and fluency in addressing emotions in real life.
These practical implications may be relevant to all healthcare professionals who have direct contact with patients. Healthcare professionals, such as doctors, nurses and speech and language therapists work in similar settings, so their organisational display rules are similar. The also work with the same patient populations, so they may experience many of the same emotional challenges at work. In addition, the function of the therapeutic relationship is constant within each of these professional contexts.
Limitations
As with all studies, there are limitations that must be acknowledged. While semi-structured interviews are a useful way to access participants perceptions, the information gained may be limited by participants memory, understanding of the topic or their willingness to disclose information. The use of observation combined with participant verification interviews in the second study mitigated some of these limitations since the researcher could ask questions base on her observations that might compensate for any deficits in participants’ memory or understanding. However, using observation introduced additional limitations since participants may act differently when being watched. Lastly, as with all qualitative research, the generalisation of the results is limited to the specific context in which the research was conducted.
Conclusion
Patients experience negative and positive emotions when working with therapists. They use emotion regulation strategies to regulate the emotions they experience and express. Although they believe they have the right to experience and express the emotions that they truly feel, they appreciate the expression of extreme emotions may have a negative effect on their therapeutic relationship. Patients use emotion regulation strategies proactively, in anticipation of an emotional event, and reactively, in response to an emotional event. Through their use of emotion regulation, patients work with therapists to build and maintain the therapeutic relationship.
Key Findings
• Patients use a full range of the intrapersonal emotion regulation strategies identified in the process model of emotion regulation (Gross, 1998) in response to positive and negative emotions.
• Patients use interpersonal emotion regulation strategies to a lesser extent because therapists do not tend to display emotions that patients believe require regulation and because patients did not think regulating their therapists’ emotions is their responsibility.
What this study has added
This is the first study to explore patients use of interpersonal and intrapersonal emotion regulation strategies used in response to positive and negative emotion within the context of therapeutic relationships. The findings make an important contribution to our knowledgebase on how patients regulate their emotions before, during and after their interactions with therapists.
Acknowledgements
This research was done as part of the first author’s doctoral thesis. Horton, A. (2018) Emotion Regulation in Therapeutic Relationships (Unpublished doctoral dissertation or master’s thesis). University of Manchester, Manchester, United Kingdom.
Footnotes
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethical Approval: Ethical approval was granted from the National Health Service via the Integrated Research Application System in 2014. (11/SW/0350)
Patient and public involvement data: During the development, progress, and reporting of the submitted research, patient and public Involvement in the research was included in the conduct of the research.
Statement of authorship: AH – did the research as part of her doctoral studies and wrote the paper. DH and GH supervised the doctoral research and the writing of the paper
ORCID iD
Ayana M Horton https://orcid.org/0000-0001-6097-4606
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