Chapter 2 Rapport
Introduction
The first and most important objective of any client–practitioner interaction is the establishment of client rapport. Aside from facilitating communication between the practitioner and client, good rapport can also improve client assessment and the achievement of expected treatment outcomes.1 Development of this relationship requires time and skill.2 As the therapist’s contribution to rapport is often overlooked in the literature,3 the purpose of this chapter will be to inform readers of the importance of establishing a strong therapeutic relationship with their clients and to provide CAM practitioners with useful strategies to improve client rapport in clinical practice. These skills may also enable practitioners to develop more effective working relationships with other healthcare providers.4 First though, an exploration of the terms used to describe rapport will enable readers to understand the context in which this chapter is situated.
Definitions
Many terms exist that describe the bond between a client and practitioner. The terms most frequently used are ‘therapeutic alliance’, ‘therapeutic relationship’ and ‘client rapport’. By definition, a therapeutic alliance is ‘ a conscious and active collaboration between the patient and therapist’.3 Similarly, a therapeutic relationship is ‘a trusting connection and rapport established between therapist and client through collaboration, communication, therapist empathy and mutual understanding and respect’.4 Rapport is defined as a ‘harmonious relationship’.5 As each of these terms incorporate similar underlying themes, including collaboration, reciprocity, parity and growth, they are considered interchangeable.
The therapeutic alliance and other similar terms are frequently cited in the psychology literature. This may be because the concept of ‘alliance’ is an integral component of many counselling models, such as the ‘here and now’ focused counselling model,6 the lifestyle-oriented nutrition counselling model7 and the four stages of therapy process.8 The latter model suggests that therapist techniques, client involvement in care and the therapeutic alliance are inextricably linked. According to Hill,8 this means that a practitioner is unable to use techniques effectively if a client is not involved in the care and there is no alliance, that a client is not likely to be involved in the care if a therapist does not skilfully use techniques and there is no therapeutic alliance, and that alliance cannot exist without a competent clinician and a participating client. In essence, what this theory suggests is that a competent practitioner who adopts a client-centred, participative and empowering practice style is likely to develop a strong therapeutic alliance. This is a somewhat simplistic interpretation of this relationship, because like other aforementioned models, it does not take into consideration the myriad factors that affect the development of this alliance, as will be elucidated throughout this chapter.
Importance of rapport
There are many reasons why CAM practitioners should be encouraged to develop rapport with their clients. On the whole, building and maintaining rapport leads to positive client outcomes.9–14 A survey exploring the views of 129 Connecticut occupational therapists on therapeutic relationships supports this claim.4 While descriptive surveys are not the most appropriate design for evaluating causal relationships, clinical evidence is beginning to mount that validates the association between good rapport and positive client outcomes.
A cohort study involving 354 patients in a community-based non-profit drug treatment program and 223 patients from a private for-profit program found lower levels of client rapport during counselling treatment resulted in poorer treatment outcomes, including greater cocaine use and criminality.15 Likewise, studies of patients with non-chronic schizophrenia,16 depression,14,17 post-traumatic stress disorder18 and alcoholism19 show that good client rapport improves treatment outcomes.
A reason why well-established rapport may contribute to improved client outcomes may be explained by increased treatment compliance.20 In support of this statement, mothers attending a Los Angeles children’s hospital reported greater treatment compliance when highly satisfied with a physician’s attitude.21 Similarly, perioperative patients who reported a higher level of satisfaction with their care were more likely to take responsibility for their decisions.22
The positive relationship between client satisfaction and treatment compliance has also been reported among patients with chronic pain,23 dermatological disorders24 and diabetes.25 Thus, client satisfaction appears to be a strong motivator of treatment compliance and, as such, maybe fundamental to treatment success. In other words, good rapport may be responsible for improving client satisfaction and treatment compliance,26 and ameliorating client outcomes.
Even though the needs of clients are a priority in any consultation, there are also professional implications associated with building client–practitioner rapport. First, strong therapeutic relationships between clients and clinicians may improve the public’s perception of a practitioner group.4 Second, by increasing client rapport and satisfaction, the risk of litigation might be reduced. Although this claim is speculative, Eastaugh 27 and Panting28 agree that improving client trust and communication, such as that developed through good rapport, results in fewer malpractice claims. Indeed, effective communication could reduce the risk of litigation by increasing rapport and treatment compliance.10,21,29 Alternatively, since good client rapport is critical to formulating adequate diagnoses,21,30 practitioners may misdiagnose less frequently.
Because the practitioner is predominantly responsible for developing and maintaining client rapport,31 the following section will highlight some useful strategies that clinicians can use to strengthen therapeutic relations and improve client outcomes.
Factors that facilitate and constrain client rapport
The clinician’s behaviour and communication style can have significant impact on the practitioner–client relationship. Therapists who are warm, friendly (p = 0.01), affirming and understanding (p = 0.05) demonstrate greater rapport with their clients than those who do not manifest these qualities.32 These attributes may also increase client compliance21 and improve treatment outcomes.33 Another essential ingredient in the development of rapport is time.
Consultation time
Developing client rapport within the first few minutes of a consultation builds client trust34 and minimises defensive attitudes by blurring the transition from small talk to formal assessment.21,35 Constraints on practitioner time, such as escalating workloads, costs, and organisational and political pressures diminish the opportunity for practitioners to build a strong rapport with their clients.4,36
Evidence from a recent survey of 186 outpatients attending a Japanese psychiatric clinic lends support to the postulated relationship between consultation time and rapport. The study found session concentration (or session duration divided by session frequency) to be positively correlated with patient satisfaction of physician communication style (p<0.05). Higher levels of patient satisfaction also predicted lower levels of depression and anxiety. The authors concluded that communication satisfaction, which was predicted by consultation duration and frequency, was indicative of a good therapeutic relationship.37 The correlation between increased consultation duration and improved physician communication is consistent with findings from an earlier study of general practitioners.38
Because time constraints are likely to have a negative impact on client outcomes,4
