Fundamentals of Client-Therapist Rapport



Fundamentals of Client-Therapist Rapport


Teri Britt Pipe



Importance of the Therapeutic Relationship


Holistic, client-focused care is a unifying goal among client care professionals. Holistic care involves viewing clients as complex, dynamic beings with evolving, developing personas, needs, and strengths. Developing and nurturing the therapeutic relationship are the keys to understanding clients from a holistic perspective. The client-therapist relationship then can serve as the foundation for assessment, prioritization, mutual goal setting, and shared decision making.


Creating and maintaining rapport are essential first steps in coming to know and understand the client. Much more than simply being nice or acting respectful, truly knowing the client is part of effective clinical care and has important implications for client outcomes. Knowing the client means comprehending the client’s physical, emotional, cognitive, spiritual, and social sense of personhood and connecting to it as one human being to another within the boundaries of a professional therapeutic relationship.


Research and theory provide evidence that knowing the client is crucial to one of the most important yet basic aspects of clinical care: ensuring the client’s safety. Learning more about clients, understanding their unique perspectives, listening to what is and is not said, and accurately reading behaviors to formulate a correct clinical impression are all vital steps in keeping clients aligned with their therapeutic program and keeping them from harm. For instance, research indicates that the clinical behaviors of knowing and connecting with clients provide protection against untoward events and promote early recognition of client problems.1 Serving as a client advocate and guarding clients’ best interests are professional responsibilities that are deeply rooted in the therapeutic relationship.


In addition to having implications for the client’s safety and well-being, meaningful therapeutic relationships also have implications for professionals. At times therapists may not be fully aware of the impact on clients of “simple” interventions, such as listening, being present, and offering encouragement. Behaviors such as these lead to knowing the client. Perhaps if therapists understand the depth of caring that can be conveyed by a simple gesture or by listening to clients talk about their experiences, they can find renewal and healing in their practice.



Developing a Successful Therapeutic Relationship


Developing a therapeutic relationship is fundamental to working well with clients. The most effective approach is guided by a theoretical context so that thoughts and behaviors can be seen in a broader, systematic perspective of caring for the client as a comprehensive whole. A theoretical perspective helps the therapist perceive, recognize, and process clinical information in a systematic way and can help bring order out of chaotic clinical data. The theoretical perspective that provides a framework for this part of the chapter is Watson’s theory of human caring.2 This model is not simply “applied to” a situation; rather, it lends itself to being experienced so that the elements of the model come alive for the participants in caring relationships and encounters.



Watson’s Theory of Human Caring


Watson’s model has gained international recognition and has been used by a variety of disciplines since its origin in nursing. For the purposes of this chapter, the therapist is the “self,” and the client is the “one being cared for.” The theory of human caring is also sensitive to the changing realities of society and health care.3 This chapter presents an overview of some of the theory’s major concepts as well as examples based on clinical experience. The three major components used to frame the discussion are caritas, transpersonal caring healing relationships, and the caring moment.



Caritas


Caritas derives from the Greek word meaning “to cherish, appreciate, and give special attention, if not loving attention, to; it connotes that something is very fine, that indeed it is precious.” Caritas characterizes how hand therapists may choose to approach their clients.



image Clinical Pearl


A positive, respectful regard for the client is the very first step in the therapeutic relationship.


Whether they meet clients in the home, hospital room, office, or other setting, therapists’ extension of a positive caritas regard for clients and their personal environment sets the stage for the development of therapeutic rapport. The ideal way to begin is to spend a moment or two mentally settling down and reaching a clear state of mind before meeting the client. This centering approach need not take a great deal of time; it requires merely the time it takes to inhale and intentionally clear one’s focus in preparation for the client encounter. It is a way of cultivating mindfulness about one’s practice.


Mindfulness is simple but not easy; it requires effort and discipline to “pay attention in a particular way: on purpose, in the present moment and nonjudgmentally.”4 The purposes of this centering moment are (1) to bring therapists awareness and understanding of their own minds; (2) to teach them how this can influence perceptions and actions; and (3) to show them how perceptions and actions influence the clinical environment, the client-therapist relationship, and the clinical encounter. The essence of mindfulness is to cultivate self-awareness through self-observation, self-inquiry, and mindful action. The overall attitude is one of gentleness, gratitude, and nurturing.4 From this point of inward clarity, the therapist can progress to the therapeutic relationship with the client. Again, this practice of focused attention need not take a great deal of time; it can be done in a moment. Yet the effects can be quite powerful because of the intention and focus this approach brings to the clinical encounter.


Watson’s theory of human caring delineated ten caritas processes,2,5–9 which are used to explore the development of the therapeutic relationship. The discussion of each process includes common pitfalls and ways the therapist can avoid them.



Caritas Process 1: “Practice of Loving-Kindness and Equanimity within Context of a Caring Consciousness”


The word practice in the definition of Caritas Process 1 is a reminder that the attitude of loving-kindness and equanimity is not something that can be accomplished quickly or permanently; therapists practice it not with the goal of achievement, but rather with the objective of becoming more conscious of how they approach clients.10 Equanimity is the quality of being calm and even tempered. It is an evenness of mind characterized by calm temper or firmness of mind, reflected as patience, composure, and steadiness of mind under stress. For the hand therapist, cultivation of this mindful, caring approach to the therapist-client relationship translates into reflections such as, “Who is this person? Am I open to participating in his or her personal story? How ought I be in this situation? What are the client’s priorities?” The client’s response is also affected and may include the person’s perceptions of how the interaction and relationship will be part of the healing process and how the client will choose to participate in the therapist-client relationship.



Common Pitfalls and How to Avoid Them





Caritas Process 2: “Being Authentically Present and Enabling and Sustaining the Deep Belief System and Subjective Life World View of Self and One Being Cared for”


Authenticity requires that hand therapists know who they are and how they can contribute to their clients’ care. Although authenticity sounds very simple, it can be counterintuitive in the context of modern standardized health care practice to remember that each therapist and each client brings something unique to the therapeutic relationship; unless therapists know their individual talents and gifts, those talents and gifts can’t be shared. Discovering one’s unique sense of authenticity involves taking the time to reflect on how experiences, clinical learning, personal knowledge, culture, belief system, aspects of personality, and a vast array of other factors unique to each individual can be cultivated to help in the current clinical situation. During this phase of the therapist-client relationship, the therapist is using his or her sense of self to be intentionally present with the client. This means being able to focus on only the client for this time. It means turning attention to what it is the client is experiencing in order to support the client in his or her belief system and discovering the things that will sustain and inspire hope or faith for that client.


In this phase of rapport building, helpful questions therapists might ask themselves include, “What information is needed to care for this person? Can I imagine what this experience is like for this client and what it means in his (or her) life?” Likewise, the client can contribute to the clinical relationship by sharing stories of his or her past as it relates to the person’s current health status, exploring sources of strength and meaning that can be used in the work of hand therapy.



Common Pitfalls and How to Avoid Them





image Clinical Pearl


Clients often are pleased and relieved to be asked about the strengths they bring to a situation, because health care providers generally ask instead about weaknesses or problems.



Caritas Process 3: “Cultivation of One’s Own Spiritual Practices and Transpersonal Self, Going beyond Ego Self”


This element of caring requires a delicate balance. Caring involves tapping into one’s own source of strength according to a personal belief system while taking care not to assume that the client shares those values. In order to use the transpersonal self, the therapist must sustain healthy personal boundaries and put aside personal concerns, worries, and needs to care for the client. This part of the rapport-building process involves supporting the client in his or her spiritual beliefs and source or sources of strength and meaning, even when those differ from the therapist’s own beliefs. Going beyond the ego self means acknowledging the uniqueness of each individual while recognizing that the connections between individuals can be used for healing.


In this phase, the therapist may reflect on a question such as, “How am I attending to this person’s spiritual needs and soul



Common Pitfalls and How to Avoid Them




1. Assuming the client shares the therapist’s belief system: Ask the client; don’t presume to know even if seemingly obvious signs are present (for example, religious symbols).


2. Failing to clarify and uphold professional boundaries: Clients can feel vulnerable and may say things to please the therapist. Always keep in mind the influence of the healer on the client, and use it responsibly.


3. Neglecting to call in resources: The trust between client and therapist is strengthened if limitations are communicated and arrangements or referrals are initiated for social workers, community providers, and other sources of help.


4. Neglecting to devote the time and energy to “feed one’s own soul,” leading to a professional sense of eroded spirit and diminished effectiveness: This is perhaps the most common pitfall among health care professionals. The remedy is to cultivate activities and recreational pursuits that strengthen the sense of self. Find a source of restoration and recreation that builds your self-confidence and self-respect. Your clients will benefit, because you will be much more effective in your professional role.


care?” The client can assist in building this part of the relationship by identifying the aspects of his or her life style that the client feels “feed my spirit.”


Precaution. Remember to use your own personal sources of strength but not to overstep professional standards regarding relationship boundaries.



Caritas Process 4: “Developing and Sustaining a Helping-Trusting Authentic Relationship”


Participating with a client in a caring, healing relationship is a choice. The therapist can “go through the motions” and still deliver safe, effective care; however, a much higher standard is set when the therapist deliberately creates the potential for the development of a healing relationship. Within this framework, the professional must cultivate a caring consciousness that is integral to the healing process, requiring self-development and ongoing personal growth.


The therapist’s thinking about the therapeutic relationship should include questions such as, “What significance does this illness or injury have for this client, and how can I honor that meaning? What are the specific forms of caring and hand therapy that will best acknowledge, affirm, and sustain this client?”


From the client’s perspective, this phase of the relationship means choosing and showing a degree of trust and openness with the hand therapist. The client may show signs of willingness to relate to the therapist by sharing experiences and deeper meanings, past occurrences, and validating the therapist’s understanding of concerns, needs, and priorities.



Common Pitfalls and How to Avoid Them




1. Getting caught in the routine and distracted by time constraints and schedules: Keep your attention and focus on what is happening with this client, in this moment. Verbally set realistic and positive expectations about time with your client by saying something such as, “Mr. Smith, we have 15 minutes together to accomplish our work. This will be ample time, so let’s get started.”


2. Rushing into a client’s space before considering the best approach: Try to imagine what it would be like to have to ask for help from someone and then having that person disrespect your sense of privacy and your need for personal space.


3. Overlooking the significance that illness, injury, and therapy have for clients: The hand therapist represents a significant source of hope, repair, and return to function for the client.


4. Failing to recognize that trust is a changing characteristic: Be patient and allow the trusting relationship to develop. Once it does, diligently guard that trust.



Caritas Process 5: “Being Present to and Supportive of the Expression of Positive and Negative Feelings as a Connection with a Deeper Spirit of Self and the One Being Cared for”


The hand therapist recognizes that within a trusting relationship, the client will feel more comfortable if he or she can share negative as well as positive aspects and can voice disagreements and deeper feelings than might not otherwise be exchanged. The hand therapist’s role is to listen to what is said and to understand what is left unsaid (that is, read between the lines). It is a good idea to confirm or validate verbally what you understand from the client’s expression. This is crucial with expressions of pain or discomfort, which is highly subjective and open to interpretation.


What is perceived becomes reality. However, two realities, the client’s and the therapist’s, operate within the relationship. Clients may be trying to assimilate what their injury, disease, symptoms, diagnosis, or treatment means within their culture or personal relationships. Clients also are often trying to get a clear picture of what the current health situation means for their life and future.



image Clinical Pearl


Keep in mind that your time will be better spent if you slow down and focus.



Common Pitfalls and How to Avoid Them




1. Feeling offended when the client expresses negative emotions or behaviors: Remember that if the client didn’t trust you, he or she would not reveal these feelings to you. Demonstrating that you accept the negative as well as the positive is one way of showing a caring attitude.


2. Forgetting to validate meanings: Verbally acknowledge the behavior or expression and verify the meaning of what you observed. For example, “You are crying and seem upset right now. I wonder if you are physically tired or maybe you are frustrated that you aren’t completing this activity as well as you’d like, or maybe it is something else. Can you help me understand?”


3. Dismissing the client’s stories as irrelevant to the current clinical situation: Remember that for the client, the story may be connected to the client’s view of his or her health condition and therapy.



Caritas Process 6: “Creative Use of Self and All Ways of Knowing as Part of the Caring Process; to Engage in Artistry of Caring-Healing Practices”


In many cases, standardized methods of structuring client care serve as guidelines for a certain diagnosis or treatment approach. The art of caring involves a spirit of willingness to explore and discover other approaches to care that build on the unique aspects of the particular client and on situations that might lend themselves to creative or artistic healing methods.11


The hand therapist might choose to address the following reflections to support the artistry of caring: “What are the unique attributes of this client and this situation? How can I use the environment to support healing for this client?”


Clients’ perspectives include determining the degree to which they feel comfortable disclosing their uniqueness as individuals and their ways of expressing themselves. Clients may also be coming to new levels of understanding about their pattern of response to the health situation, changes in roles and responsibilities, and how their lifestyle may change.


Creative innovations can be very simple, and many hand therapists incorporate artful insight into their practice with each client. Such innovation could involve simply finding out the kind of food the client likes to cook or eat and then facilitating some aspect of that food preparation as part of hand therapy, or finding out the kind of music the client enjoys and incorporating that into the practice environment. If the client enjoys writing, the hand therapist may ask the client to keep a journal of what the recovery process means to him or her, describing important milestones and setbacks along the way.



Common Pitfalls and How to Avoid Them




1. Failing to consult the client regarding preferences about artful ways of caring: Remember that some clients are more willing than others to incorporate nontraditional approaches. The client’s comfort level is always the guide.


2. Becoming disappointed or discouraged if an artful approach does not work: Role model the qualities of persistence and optimism for the client.


3. Forgetting to ask about role changes and significant issues: Take the time to figure out what this illness or injury means to the client as you go about designing an artful approach. For example, if a pianist is working to recover from a hand injury, the significance of using music in the therapy will rest on whether the client finds this approach motivating or if it is a source of despair.


4. Moving too quickly into the artful approach without building a sense of rapport: Wait until you can gauge the types of approaches to which the client might respond, and then share the ideas with the client at the appropriate time.



Caritas Process 7: “Engaging in a Genuine Teaching-Learning Experience That Attends to Unity of Being and Meaning, Attempting to Stay within the Other’s Frame of Reference”


Teaching and learning are key activities in the hand therapist-client relationship. The hand therapist’s role is to create a teaching-learning environment that supports the client’s progression through healing.



image Clinical Pearl


Although the primary outward activities of hand therapy involve the body, a significant part of treatment also involves the client’s mind and spirit.


Teaching requires attending to the client’s ways of learning and preferences for information exchange and decision making. The hand therapist may ask, “Is this person able to understand what he or she is experiencing? How can I share knowledge and expertise with this client in a way that is relevant and meaningful for facilitating self-healing?”


It is very important to ascertain the client’s definition of health, healing, and wholeness so that the therapist can incorporate this into the teaching-learning plan. The hand therapist also must assess the client’s understanding of self-care needs, limitations, resources, and strengths.



Common Pitfalls and How to Avoid Them





Caritas Process 8: “Creating a Healing Environment at All Levels, Physical as Well as Nonphysical, a Subtle Environment of Energy and Consciousness Whereby Wholeness, Beauty and Comfort, Dignity, and Peace Are Potentiated”


The hand therapist can work with the client to create the best environment, physical and nonphysical, to promote healing. Manipulation of the environment can range from basic methods to more complex approaches. The treatment environment should be well-lighted, ventilated, and clean. Beyond that, the hand therapist can incorporate elements of beauty, including sources of color, movement, texture, and form, to enhance the healing environment. When possible, a view of the outdoors, a change in surroundings, paintings, flowers, plants, and music can also be included. It is important to eliminate or reduce unnecessary noise, clutter, and other distractions from the environment during the clinical interaction.


The hand therapist can focus on questions such as, “What is important to this person to make his or her experience comfortable? How can healing art be incorporated into this space and time? How can I use creativity in managing institutional imperfections, constraints, contingencies, and scheduling issues while sustaining the context of a healing environment?” The client’s role is to participate with the therapist in the creation of an



Common Pitfalls and How to Avoid Them



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Sep 9, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Fundamentals of Client-Therapist Rapport

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