One of my favorite primary care physicians offered all of her patients a hug at each visit. When asked why she said, “Every person deserves a hug each day. They need to know someone cares.” While her method of creating a therapeutic relationship may have been unorthodox, she demonstrated the relationship’s value and her stance toward her patients through her actions. In this post-COVID-19 pandemic world, there are few physicians, if any, who would hug their patients at each visit. Fortunately, there are other ways to create a therapeutic relationship in medical or psychotherapy treatment.
Is the therapeutic rapport really that important?
Effective psychotherapy begins with the creation of a therapeutic rapport as a precursor to the therapeutic relationship. In the initial stage of therapy your therapist works to establish a therapeutic rapport with you by helping you feel comfortable and understand the therapeutic process as well as how it might be helpful. While some individuals come to therapy with the goal of making behavioral changes, others begin sessions simply because they want to feel better. Establishing a rapport with you helps your therapist understand where you are in the process.
The importance of the therapeutic relationship cannot be overstated. Research has shown the relationship to be one of the most important factors of treatment outcome regardless of treatment modality or theoretical orientation. Clients and therapists who partner and collaborate to establish a strong early therapeutic rapport will likely maintain and grow the therapeutic relationship leading to a greater likelihood of symptom improvement. This rapport requires trust built upon various factors including the therapist’s empathy, positive regard, genuineness, and authenticity toward the client. Let’s dig a little deeper into these factors.
How does a therapist develop therapeutic rapport?
Empathy
According to Psychologist Carl Rogers, developer of the client-centered psychotherapy approach and the concept of unconditional positive regard, empathy is your therapist’s “sensitive ability and willingness to understand [your] thoughts, feelings, and struggles” from your perspective (p. 85, cited in Elliot, Bohart, Watson, & Greenberg, 2010, p. 13). Rogers further defines empathy as “the ability to see completely through [your] eyes, to adopt [your] frame of reference… entering the private perceptual world of the other… being sensitive, moment by moment, to the changing felt meanings of which [you are] scarcely aware” (p. 142, as cited in Elliott et al., 2010, p. 13). Empathy has been found to be a crucial component of effective treatment regardless of the theoretical orientation, treatment format, or level of client problem severity. Empathy has also been associated with better outcomes with less experienced therapists. If you are wondering what it looks like when a therapist empathically hears a client and treats them as a person of worth, take a look at Joe’s story.
When 43-year-old Joe arrived for his initial therapy appointment he felt rushed and angry. He had already had an argument with his mother and missed his bus that morning. And to top it off he had to wait an extra 10 minutes before seeing his new therapist. Joe, who had been previously diagnosed with schizophrenia, expressed his anger at today’s problems, his siblings, his co-workers, and anyone else he felt had disrespected him including the therapist. Although the therapist initially felt threatened and defensive, she understood the importance of establishing the therapeutic rapport. So she shared her sense that Joe often felt misunderstood and not taken seriously, which validated his concerns. Once he felt that he had been heard, Joe calmed down enough to participate in the session.
After encountering disrespect in a variety of situations, Joe expected the same from his new therapist. However, through her empathic stance, she understood Joe’s thoughts, feelings, and struggles from his perspective.
Positive Regard
Research has shown that treating clients in a highly regarded, supportive, and cordial manner does more to promote psychological growth and emotional healing than does a therapist’s neutrality or intellectual understanding. Rogers believed therapists could enhance or devalue a client’s self-worth by their attitudes or behaviors. Studies show it is important that therapists communicate their positive regard for clients directly. A client’s belief that the therapist is concerned about them is crucial for clients when encountering high stress. Karen’s story illustrates her therapist’s validation of the work she was investing in the process.
With a long history of depression, abusive relationships, and isolation, 33-year-old Karen had been seeing her therapist for more than a year. While she had made great strides, feelings of hopelessness were increasingly prevalent in her life. Karen shared her doubts about the future and her ability to withstand her painful experiences during her session. After initially reflecting upon his own feelings of discouragement, the therapist thought better of trying to talk Karen out of her depressive experience. Instead he offered his observations.
“I hear that you are really down and feel defeated. Can I offer you some feedback? I’ve watched you over the last year battle through in ways that I can’t help but admire. You’ve committed to the therapy process, even when it felt hard to engage in it, and you have taken steps in your life that are nothing short of courageous. The proof of this Karen is that you are sitting here, telling me how much you are struggling, and yet you came today and had enough trust in this relationship to share something that feels really hurtful.”
Karen’s therapist held her perseverance and commitment in high regard. He affirmed her efforts and encouraged her to continue the work.
Genuineness and Authenticity
For many individuals the therapeutic relationship is the only relationship in which they feel genuinely accepted, valued, and respected. The therapist models agreement or harmony between themselves and the client which may involve offering honest, sincere, and respectful opinions, thoughts, and feelings, as well as pointed questions, self-disclosure and feedback regarding client behavior. Effective therapists share this information in a way that is not harsh or critical of the client. In the scenario which follows, Richard’s therapist understood his frustration and was willing to sit with him through the healing process.
Richard was a retired Marine who had spent multiple tours in combat. After leaving the military he secured a job with a federal agency which hired a large number of veterans. For many years Richard experienced post-traumatic stress disorder (PTSD) symptoms in the form of nightmares, flashbacks, numbing and hypervigilance. He attempted to self-medicate with various substances including marijuana and alcohol. Richard entered treatment after a positive drug test which endangered his employment. In a particularly intense session, Richard demanded to know when he would feel better and his PTSD symptoms would stop. He had left the military years ago but could not seem to shake the symptomatic experiences. Torn between his desire to mitigate Richard’s anxiety and the need to provide insight into the uncertainty inherent in the healing process, the therapist used his own sense of hopelessness to connect to Richard and allow for deeper work.
“I can feel how excruciatingly painful this is for you. I too relate to your need to have immediate answers. The truth is, I wish I could give you immediate answers but I can’t. What you experienced while in the military was unimaginable, and I don’t think anyone could make sense of it. I can’t immediately take away your pain. What I do know is that I am willing to sit with you and go through this process with you. I am confident you can receive some sense of peace and resolution.”
Ricard’s therapist respected and valued their relationship enough to share the truth about the therapeutic process as well as his determination to work with him through it.
How can I recognize a strong therapeutic rapport?
As noted, empathy, positive regard, genuineness, authenticity are some of the factors contributing to the establishment of a strong therapeutic rapport. Each of these factors should be implemented in ways that foster your values and goals. If you wondering about the therapeutic rapport shared with your therapist, ask yourself the following questions:
- Does my therapist seem to be on my team and advocate for me?
- Do I feel heard by my therapist?
- Does my therapist treat me in a warm, supportive manner?
- Does my therapist treat me as a person of worth?
- Does my therapist understand who I am, how I tick, or why I’m here?
What’s the bottom line?
Establishing a strong therapeutic rapport capable of maintaining and growing the therapeutic relationship is critical to successful psychotherapy. Research shows this relationship to be more impactful than any treatment modality, theoretical orientation, or level of client problem severity. A strong therapeutic rapport based on trust using the building blocks of empathy, positive regard, genuineness, authenticity leads to a greater likelihood of symptom improvement. You deserve to have a therapist who is your advocate by whom you feel heard, supported, understood and respected. When searching for a therapist, seek out one who cares and is capable of demonstrating it. In other words, find a therapist who can give you a “verbal hug” which can be just as effective as the physical one from my primary care physician.
References:
- Therapy in the Real World: Effective Treatment for Challenging Problems
- Nancy Boyd-Franklin, Elizabeth N. Cleek, Matt Wofsy, and Brian Mundy