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.

Although these studies suggest that the development of rapport may benefit clients receiving psychotherapy, data on the effect of good client rapport on the outcomes of interventions in other healthcare fields are lacking. In particular, further research is required to ascertain whether changes in CAM practitioner behaviour can improve treatment success and reduce unnecessary demand on existing health services.

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.

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 adequate consultation time is as important as effective communication skills. Thus, practitioners of professions that necessitate longer consultations, such as CAM, may have the capacity to establish greater rapport with their clients than practitioners constrained by time. For clinicians whose time is scarce, strategies such as providing a quiet environment, actively listening, avoiding interruptions and displaying non-hurried actions³¹ may portray to the client that the practitioner has time to listen, which may in turn facilitate greater disclosure of client concerns. Even though these strategies may assist in developing rapport between practitioner and adult clients, children may require a more distinctive approach.

In a study of 64 3.5-year-old children, the effects of practitioner–child interaction on the establishment of rapport were investigated.³⁹ Children left alone in a playroom remained with a stranger longer when the stranger greeted the child quickly but interacted with the child for a greater period of time. Conversely, children who were approached gradually but only interacted with the individual for a brief period of time were also less likely to leave the playroom. Unlike adults, too much time spent trying to establish rapport with a child may inversely affect the establishment of this relationship.