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Building Rapport in Therapeutic Setting


Riya Vaid

19th April, 2024




-Tony Robbins

Client-Therapist relationship becomes effective by using right communication skills to develop a relationship built on trust and reliance where the client is freely able to speak about their problems to their therapist. Trust and reliance on the therapist may or may not take time to develop depending on the skills used to build rapport. Rapport building is the process of connecting with others, in this scenario, the client, to create a harmonious and trustworthy environment in the space and in the relationship between the client and the therapist. Rapport, to be specific, is the ability to create a connection with others in such a manner that the client-therapist relationship is built on trust and understanding (Zakaria & Musta’amal, 2014).


To be specific, the climate or environment is developed such that the clients feel safe and can build a relationship of trust and intimacy. According to Aaron Beck, Rapport is established by finding astuteness which can be guessed with the help of the case history taken by the therapist and finding a common ground between the client and the therapist. Here, the therapist has to look upon the areas which are quite important for the client or they prioritise that area of their life a lot (e.g., their interests such as photography or the place they reside in). Therapists here use them as a medium to build the needed connection.


For example, the interviewer in the session with Dr. Beck, herself a CBT practitioner, mentioned that one of her clients, who suffered from schizoaffective disorder, had depression as one of the co-morbidities, and was still engaging in daily chores such as cooking. She liked doing so. The therapist used that as a medium to build the connection where the client was able to introspect that she was capable of doing something and bringing a change in it. Here, the therapist delved into self-disclosure to a certain extent when the client shows resistance (Beck Institute for Cognitive Behavior Therapy, 2014). This shows that self-disclosure to a certain extent helps in breaking the walls the client has built around themselves and eventually, openly speaks about their problems. Self - disclosure, here is one of the approaches of rapport building.



Rapport building is a continuous process and if there is any occurrence where that rapport gets destroyed, it has to be rebuilt using new approaches. It is also noted that the period of the entire therapeutic journey affects the rapport-building process. In brief therapeutic sessions where the therapist focuses on solutions rather than problems, which is also short-term in nature, the pace of rapport building is faster compared to the regular therapy sessions. Here, too, different approaches that directly target the characteristics of rapport building are used, which may be beyond matching, mirroring, and leading. 


Characteristics of a Good Rapport

To have a deeper understanding of rapport, it is important to get exposed to the terms or rather, the characteristics of the therapist that help in the rapport-building process. According to Rogers (1977), three characteristics or attributes of the therapist that contribute to a healthy therapeutic relationship - congruence/authenticity, unconditional positive regard, and accurate empathy (Person-Centred Approach). Here, congruence/authenticity refers to the extent to which the current actions of the therapist align with their true self, i.e., whether they are authentic or not, and that the client can trust that person because of their authenticity (Rogers, 1977). This is usually observed through their credentials (degree(s), certifications, universities and organisations that trained them, years of experience), referrals, and reviews. Congruence or authenticity may sound necessary for a therapist to maintain complete transparency, which is not true.


Selective transparency (only sharing certain aspects of the therapists or a limited amount of various parts) can be of use. Unconditional Positive Regard, according to Rogers (1977), is about a therapist accepting and supporting their client without making them feel judged or evaluated, irrespective of the client’s sayings and background. Therapists here accept their clients as they are. The more the therapist cares, accepts, and values their client, the more the client can imbibe therapeutic interventions, which in turn, positively impacts their therapeutic alliance and relationship, but the state of complete acceptance and unconditional caring may not always be plausible for every therapist (Rogers, 1977). Rogerian Accurate Empathy is defined as the ability of the therapist to understand and precisely reflect the client’s thoughts, feelings, and experiences from the client’s perspective. As Rogers focused on Person-centred approach, accurate empathy is essential to look at the client’s feelings and explore them from their perspective as the leverage is given to the client, allowing interpersonal growth as well as a sense of conditionality facilitated among the clients (Rogers, 1977). 


A new theory on the attributes that therapists should possess while building rapport is given by occupational therapy researcher Linda Tickle-Degnen and behavioural psychologist Robert Rosenthal that depends on the dynamic structure of three interrelated components: mutual attentiveness, positivity, and coordination. Mutual Attentiveness or the expression of mutual attention focuses on how important active engagement in attention is for both parties. This arises by making eye contact, body posture that exhibits active listening by the therapist, and giving cues that show the therapist is understanding and acknowledging the client’s feelings (Rognen & Rosenthal, 1990). While positivity deals with maintaining a supportive and constructive ambiance in the therapeutic space. This aids in rapport by developing feelings of mutual friendliness and caring. It can be encouraged by expressing warmth, and genuineness, and acknowledging the client’s individuality. Though a close correlation is observed between the degree of involvement and mutual attentiveness, they may not give interpretations in similar directions. By this, it can be meant that although positivity and mutual attentiveness are positively related, one has to show high levels, for other components to be present at the same level.


Lastly, Coordination highlights the balance or harmony between the two bodies or parties of individuals, analogous to homeostasis maintained in the human body. This can be demonstrated by mirroring the client’s body posture, gestures, deportment, tone of voice, pace, and breathing rhythm. Here, it has to be noted that mirroring is a natural process but might be ineffective verbally. Verbal cues have to be incorporated by the therapists heavily to ease the process of breaking the client's resistance. Milton Erickson used them to create a sense of safety and trust and facilitate deeper connections with clients during therapeutic sessions. Matching, Mirroring, and Leading are the building blocks of good rapport. By mirroring and matching the client’s body posture, the client unconsciously notices these similarities.


This helps in tuning out a connection and building good rapport. Leading the client towards the client is a gradual process, which may not take work if the therapist is on a time crunch and especially at times when the client is reluctant. It was emphasised by Degnen & Rosenthal, 1990 that the close interconnection between the positivity and coordination components of rapport may not be equivalent. It is situational, if one component shows high levels, the other exhibits low levels. It is observed that the early stages of developing a relationship or intervention are weighted more on mutual attentiveness and exhibiting interest as the components of the rapport, which means that high levels of mutual attentiveness are observed at the beginning, and later, a gradual shift is observed from mutual attentiveness to coordination where behaviours like smooth communication, and fewer misjudgments are prioritised. The prioritisation of the components may vary depending on the goals of the intervention that needs to be fulfilled. 


Significance of Rapport Building

Rapport, as previously mentioned, plays an important role in the therapeutic relationship which is built on trust, intimacy, and reliance. Therapy is a gradual process where it takes time for the clients to open up about their problems to the therapists. At times, the clients may need to be encouraged or probed to break the barriers that have been built up due to several existing factors in the life of the client. Sharing the information about self may get emotionally overwhelming or burdening for the client; and at that moment, the client can feel safe and relaxed when a strong rapport has been developed by the therapist. It is to be noted that not every counsellor or therapist relationship may not work, but this does not relate to the therapist being bad. They may not be the right match for the client. Building a good rapport can be a step towards integrity and honesty. A study was conducted to examine the positive effects of rapport building on eyewitness memory where high or low rapport was built with 233 undergraduates using a videotaped mock crime before or after they received post-event misinformation. Later, they were interviewed about the mock crime.


It showed that high rapport before misinformation increased the amount of accurate information reported in a subsequent witness interview compared to low rapport (Kieckhaefer et al., 2013). This shows that a good rapport does not just make the bond between the client and the therapist strong but also because it has an impact on an individual’s ability to interact with others progressively or productively. 

Rapport needs to be built not just in a therapeutic setting but at every juncture of one’s life because it plays a vital role in the overall growth of an individual or a relationship, or an organisation.


Rapport establishes a safe and non-judgmental environment where comfort is created for the client to draw down their reluctance or resistance to express their feelings or opinions on the problems they are facing openly. The safe environment created by the therapist allows the client to talk to the therapist about sensitive and personal information without being criticised or rejected. The therapist engages in the act of confidentiality, active listening, and empathy which maintains this environment, helping the client to build trust in their therapist. Security aids in better insight into the client’s true or honest thoughts, feelings, behaviours, which also maintains authenticity in the therapeutic relationship. Rapport acts as the building block for progressive growth in therapy.


A good rapport helps in bringing out the results or outcomes at a faster pace. Once the connection between the two parties is built and the trust has been fully developed, willingness comes into the picture, making the client voluntarily engage in the therapeutic process and draw solutions to the complex issues, enhancing self-reflection, insight, and personal growth. Support received from the therapist makes the client work hard towards the goals and make positive changes in their lives. This makes them feel that they have been heard, seen, and understood by their therapist. The sense of validation is necessary as it promotes the process of healing and growth. Acknowledging the client’s feelings and perspectives is necessary to make the clients feel valued, respected, and accepted. This helps in the exploration of their emotions in a deeper sense and promotes self-awareness. Empathy, plays an essential role in building and maintaining the therapeutic alliance between the client and the therapist. It helps the therapist express their genuine concern about the client’s thoughts, feelings, and perspectives and their overall well-being. It also gives the framework for exploring complex emotions, processing trauma, and working through challenges. 



Skills for Rapport Building

Building rapport in the initial stages of therapeutic relationship is important as it helps in the ease of communication, the process of sharing the feelings or the thoughts clients have becomes smooth. For this, therapists need to acquire the core communication and verbal skills for building rapport, such as empathy, active listening, shared experience, similarity, and many more. Empathy creates and stabilises a therapeutic atmosphere into a positive one, by understanding the needs and requirements of the clients, and influencing their behaviour and emotions. A comprehensive therapeutic model was developed by Norfolk et al., 2007, focusing on several motivational and skill elements, along with verbal and non-verbal communication, by meta-analysing past research papers that would enhance the therapeutic rapport. The following model highlights how empathic motivation and a set of empathic skills along with communication skills facilitate the empathic understanding of a client's perspective. It can be enhanced by using techniques like active listening (where the therapist tries to understand the client’s perspective by attentively listening to them, understanding their body language, and emotions), questioning, and paraphrasing - where therapists have to pose useful questions like reflective questions to check their understanding about things the client has shared, paraphrasing or summarising helps in double checking the problem that has been shared by the client. This makes the client feel heard, impacting the positivity and reliance on the alliance. 


Authenticity or congruence is the extent to which the therapist’s current actions align with their true self, and how they portray their real self in the therapeutic session. Incongruence can affect the genuineness that has been built in the therapeutic relationship, eventually affecting the rapport. It helps in developing trust and intimacy which is a must in the entire therapeutic journey. According to self-determination theory (Deci, 1980; Deci, 1985; Ryan, 2000, Ryan, 2002), people are authentic when their actions reflect their true selves. Here, authenticity also is referred to as acting out of autonomous motivation rather than feeling compelled to action. While building rapport, the therapist has to ensure that the bond is based on genuineness as it helps in maintaining positivity and increases productivity, eventually speeding up the therapeutic process.


This can be developed by heightening one’s self-awareness - this can help the therapist understand how the preferences, experiences, and identities of the client and the therapist work together to recognise their adaptability depending on the situation they are in. Being transparent about the limitations of the boundaries set in the therapeutic approach helps the client’s expectations about the framework of the therapeutic approach i.e., steps taken to reach the goal or outcome that has been set or anticipated to be fulfilled become known. Self - disclosure i.e., sharing appropriate and relevant personal experiences or feelings with another person for building a transparent relationship, in this case, the client, makes the therapeutic bond genuine and strong and serves the client’s therapeutic goals rather than the client’s needs. 


As suggested by Dr. Aaron Beck, an American Psychiatrist and the father of Cognitive Behaviour Therapy (CBT), finding common ground between the therapist and the client by showing interest or curiosity in the topics that the client likes, creates a sense of familiarity, and comfort, and affinity. Similarity is a principle used to develop genuine rapport, which can be achieved with the help of three important techniques - mirroring, matching, and leading. Milton Erickson has extensively talked about these techniques where the concept of mirroring can be understood by the use of imitation such as mirroring the tone of voice or the speech patterns the client uses. This creates a sense of connection and trust as the client involuntarily notices the similarities that are shown by the therapists, breaking down the client’s resistance if present, and causing the client to open up easily. Matching involves the therapist matching with the client’s energy level, emotions, and communication style, which shows that matching is more than a mere imitation. This helps the therapist reverberate with the client’s experiences and build rapport effectively. Leading is the next step taken by the therapist after the techniques - matching and mirroring are successfully applied. It involves the clients being guided carefully and humbly toward positive change and/or insights, eventually, empowering them to explore solutions and make progress in therapy. 


Other than these, rapport can be built by talking about personal experiences (stories or anecdotes) that soften the blow of shame and isolation that the client experiences. Shared experience serves as a key ingredient in rapport building. This can be effective especially when the clients are struggling with common life challenges or mental health issues. But while sharing personal experiences, the therapist has to maintain their professional boundaries and the therapy should be centred around the client’s needs and goals. Also while sharing personal stories, it should be relevant to the case considering the factors of therapeutic goals, client preferences, and ethical guidelines. 

Non-verbal communication, just like verbal, plays an important role in identifying the client’s behavior or thinking pattern.


By reflecting and clarifying what has been shared by the client, maintaining eye contact, and mirroring their actions positively, for example, leaning towards the client but maintaining a distance to ensure the client’s comfort, not making the use of inappropriate body languages such as postures that show that the therapist is underconfident, postures that give off the impression of fatigue that would suggest disinterest in the client’s problem, using the techniques like matching and mirroring, lowering the tone and talking on a slower pace to make the clients feel calm but also make them aware of the fact that the tone used by the therapist shows that they are decisive and knowledgeable and able to guide the client - voice of confidence and certainty, facial expressions that exhibit genuineness and sincerity - face displaying the emotions of concern, thoughtfulness and enjoyment, using the acceptable gestures of nodding and making encouraging sounds, using hand gestures that are not abrupt or frantic to alarm the clients about the feelings of nervousness the therapist might have, and other techniques can help in creating a positive and trusting relationship with others.


This communicates respect, interest, empathy, and openness. To further understand this, it is like a channel of open communication in the establishment of trust between the therapist and client, with verbal clues like eye contact, facial expressions, and body language communicating empathy and real authenticity which promote a feeling of transparency and openness. In addition to that, nonverbal clues equip psychotherapists with a higher level of perception which helps them to understand their clients' feelings which can be well hidden, hence disclosing more about the clients' experience. This can add texture to understanding between parties since emphasising the multi-dimensionality of the shared meaning can also make communication deeper and more involving to both parties. Moreover, nonverbal communication has a face-saving capacity, enabling therapists to cross cultural boundaries about communication patterns with high levels of sensitivity and respect. To put it simply, nonverbal communication can be defined as a primary component in assembling a solid therapeutic alliance rather than serving as a prerequisite for therapeutic success.

When Rapport Is Not established In Therapy

At times, there are possibilities of the rapport not being established in the therapeutic alliance. This is not because the therapist has no interest in dealing with the client’s problems that they are sharing or because the therapist wants to vicariously experience the pain the client is going through. There is a set of reasons for it to be ineffective. Some of the factors are miscommunication, lack of trust, reduced cooperation, decreased engagement, difficulty in resolving conflicts, limited influence, negative atmosphere, hindered relationship building, and missed opportunities. 

Specifically, when there is no rapport in the therapy, this means that either the approach used to build the rapport was not robust or the therapist is still new in the field. Rapport is established through the expression of sincere, and, also, mutually accepted trust, understanding, and respect. These days, the therapeutic alliance and the establishment of trust between the therapist and the client is critical as this will prevent the clients from shying away from opening up about their emotions and experiences. They could be hesitant to say or tell vital personal data or discuss sensitive issues, wondering why the therapist might misunderstand them or see them as equipped with the negative things they are not bothered about.


For an environment of trust, security, and safety to be developed the presence of distrust is not good. Proper communication is a vital tool in therapy, which can be utilised in discussing problems, among others. It helps in facilitating change for individuals. Without rapport, there might be communication obstacles arising when someone is unclear, gets the wrong message, or finds it difficult to express what he or she wants to say. Often, clients cannot find the proper way to explain their problems, which might lead to their frustration. Additionally, a feeling of not being listened to or taken seriously could be developed. The human experience is a powerful tool to bond clients and therapists in the process of treatment. It encourages clients to consciously engage in goal-setting, self-exploration of different life challenges and finally devising strategies that will drive the change they desire for themselves. The absence of a therapeutic alliance would imply that the patient could disregard the therapy or maybe over-cautiously oppose the therapeutic interventions, thus making recovery unnatural and having no positive outcome. In the meantime, the therapy as a procedure is liable to produce shallow and, therefore, ineffective results in the long run in connection with solving the initial problems.


Clients can often hang up when they get comfortable while exploring the issues they have rather than preventing deep insights and further progress. The relationship of intimacy may be broken down and lead to the client being under pressure and feeling mental discomfort for the therapist as well. The customers easily decide to get frustrated, dissatisfied, and disconnected from the therapy. There is no question that it is likewise, the professionals working in the field may face some struggle or feel unable to get close to their clients. Through the relationship interchange, rapport is one of the fundamental aspects of psychotherapy. Usually, it is acquired with the client and therapist spending time, effort, and patience for a strong therapeutic alliance to be formed. 


The rapport-building process may be affected if the therapist comes out to be too formal or unrelatable - the therapist may have to disclose some personal experiences for the client to normalise the situations which can be sensitive for them to share, but not to the extent that the client catches the therapist bluffing or cooking up the stories just to build a rapport; bringing up topics that can be one of the controversial subjects - this can make the client feel uncomfortable and the client might close up; assumption at every point of the intervention may eviscerate any rapport that has been built - actively listening to what the clients are saying and reconfirming by paraphrasing or summarising everything or using client feedback shows that the therapist is attentive, that bonds the therapeutic alliance into stronger one. 


There can be reasons for rapport not being established. It can be both due to the client’s resistance and the therapist's resistance. In the case of client reluctance, as the client gets forced to seek help by the third party, unmotivated to deal with the problem can affect the rapport-building process. In client resistance, though the client is motivated enough to speak about the problem, their hesitation to speak about it because of the chances of being scapegoated or the feeling of being overwhelmed caused due to emotional pain, change in perspective, or enhanced awareness that counselling demands, can make them resist the therapy and may show signs of unwillingness, unreadiness, opposition to change. At times like this, the therapist can use the methods of persuasion or confrontation subtly to approach the aspects that are causing the clients to resist the rapport-building with the therapist. Therapist resistance can also affect the process. It can be due to countertransference where the ability to remain neutral and empathetic is affected by the biases or assumptions that the therapist holds. This may lead them not to deal with that topic or avoid it as it makes them uncomfortable to talk about.


Compassion fatigue can be one of the important factors enhancing the counsellor resistance. Burnout due to emotional turmoil of constant support and empathy towards the client with no positive outcome can lead to decreased motivation, empathy, or effectiveness in therapy sessions. Fear of failing the clients due to the perception of the therapist being deemed ineffective can lead them to resist addressing challenging issues in therapy. 


The therapist can learn to know when there’s a need to re-establish the rapport, with the help of non-verbal cues - signs of tension, disagreement, distraction, or lack of eye contact; verbal cues - change in the client’s mood by the alteration of tone which may sound defensive or dismissive or even silent, language or the level of client interaction; lack of progress - when the client does not show desired development or willingness to comply to treatment; expressed discomfort - when the client expresses some concerns, dissatisfaction or fiduciary problems with the process or the therapist; shift in session dynamics - heightened tension, conflict, lack of collaboration, etc. Once the therapists are aware of these factors, they can use strategies such as acknowledging and validating the feelings of the client and allowing them to be straightforward and assertive and reassure that they have been heard. Therapists can examine the reasons within themselves, in the client, or in the relationship that can be the cause of diminished rapport.


Therapists should promote open communication, a dialogue of sorts that lays the foundation for successful therapy with the help of clearly stated goals or expectations. A plan can be prepared to earn the trust back by expressing empathy, consistency, and sincere care about the welfare of the client. Modifications to tailored approaches or procedures can be explored by the therapists catering to the client’s unique preferences or needs. Therapists or in general, every professional undergo supervision when they want to practise new skills or techniques that have just been introduced into the field. Usually, the purpose of supervision is multiple, especially focusing on, education, guidance, knowledge transfer, and even therapeutic. It is a process that provides a scope of improvement for the therapists or MHPs to enhance their skills, and attitudes in giving quality care to the clients. Sometimes, the therapist, to deal with their set of problems, undergo supervision - when they are dealing with compassion fatigue, to support professional development, improve the work environment, to ensure that they are ready to counsel without the need for further supervision. Undergoing supervision can help therapists redraw their professional boundaries and work on their skills that can help in the entire therapeutic process and come up with a better and positive outcome. 


In essence, the therapeutic alliance is developed with apt communication skills that nurture trust, reliance, and openness, for the client to open up to the therapist easily, helping in achieving the set goals and/or expectations. Rapport rapport-building process requires the skills comprising congruence, unconditional positive regard, and accurate empathy as suggested by Carl Rogers, which later was modified to Mutual Attentiveness, positivity, and coordination. Creating a safe space is a must in this process as it enhances self-expression and growth. It demands the techniques of active listening, questioning, mirroring, matching, and leading aiding in bridging the gaps. Challenges may arise if the rapport is not established properly leading to miscommunication or resistance, requiring the therapists to re-build the rapport. Self-awareness and adaptability to approaches are essential as it emphasises fostering healing and growth in the therapeutic journey.

 

 

Riya Vaid is part of the Global Internship Research Program (GIRP) under IJNGP.

 

TAGS RAPPORT | COUNSELLING | THERAPEUTIC ALLIANCE





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