- An advanced degree in mental health only goes so far in helping people change. The critical factor is in establishing a therapeutic alliance.
- Rarely is there a perfect fit between therapist and client since the client interprets the therapist in known and unknown ways.
- A professional obligation of a therapist is to never be judgmental; otherwise, the client may shut down.
The key to therapy is the therapeutic alliance. Absent a working relationship, therapy goes nowhere. This is why psychotics are hard to treat. The process of communication and reality are different, so no working alliance can be formed, or at least that has been my direct experience.
In fact, the clients who lack trust or empathy often fail to seek therapy, and if they change their mind, it takes a while, if ever, to establish a working alliance, in medicine a facet of the "bedside manner." This is client "capacity." The other three key elements are commitment, therapist background, and goal setting.
A new therapist can be overflowing with book smarts, but every therapist has unique qualities that work for and against establishing therapeutic rapport. You know in your personal life when you click with another. The same goes for therapy, which is much more personal and prolonged than physical medicine.
The alliance process begins upon the first contact. Therapists, unlike large medical practices, contain multiple layered intermediaries who answer the phone. You never call and talk to "the doctor." This becoming a client process differs if in independent practice. This initial sense of a client takes place by phone. There is an art and a science to determine if there is a good fit. Usually, at the most basic level is fees and geography, then availability.
This story is true and hard to believe. My first "almost client" committed suicide the day before the meeting. However, the person was not my client yet. All new graduate students were assigned a mentor therapist. I was assigned to a woman who had a new client, a younger male, as I was at the time, about 22 and fresh out of undergraduate. The mentor was near retirement and believed the referral would be a better fit. That made sense. She scheduled everything, and I was to go there and do an intake and be observed. He killed himself the night before that first appointment.
Suicidal ideations can culminate in a suicide if a therapist is not careful
I always wondered if I had seen him once, and that happened. In my 50 years of seeing thousands of clients, I have never had suicide. Suicidology is a sub-specialty in mental health care.
Often, seeking and receiving immediate care is a great relief providing the mental energy to act on previous suicidal ideation. All psychiatrists know if prescribing a powerful antidepressant, there is a post-month or two danger zone. The client complains about having to come in so often, but this care is necessary.
If a client sees a psychiatrist for medication and works with me, I immediately notice changes in mood, alertness, attention, insight, and energy. The psychotropic drug (that usually takes a few weeks to change neurochemistry) helps me work with the client, who is now less burdened by hopelessness. My therapy and rapport provide additional hopefulness and optimism. This one-two psychiatrist-psychologist punch is the ideal, especially with PTSD or coping with a recent loss.
Tips on establishing rapport with Axis I (abnormal psychology) and II (personality disorders) clients
Obviously, Axis I and II overlap labeled "psychopathology." Once a client seems motivated to continue, there are ways to ensure more effective care. The second session is the key, like the second draft of a novel now that the story arc has been roughly defined.
The first session addressed the crisis, but the second session sought to diagnose and treat it and motivate the client to continue. Therapeutic rapport also enhances compliance, from showing up to doing the "homework." I also ask all clients, "How are things going?" to instill a sense of responsibility and stake in the outcome.
Other positive rapport building includes active listening, contingent feedback, and listing what is working so it can be repeated.
Practical challenges of establishing rapport with Axis II borderlines
In Axis I disorders (anxiety, depression, sexual problems, and so on), there are always more problems to discuss, and the client is rational with the mood, more lighthearted, and fun. The Axis II clients are not like this. The borderline clients with personality problems rarely establish a great rapport, and are angry and hostile with negative transference. They may have a distorted and insecure self-concept, and some are functional psychotics or have undiagnosed neurocognitive disorders (e.g., early-onset dementia).
A seasoned therapist should expect this emotional instability. The Axis II client lacks a rationality filter and is hard to work with and not fun. In fact, dialectical behavior therapy (DBT) gave up on changing a borderline and simply accepts them the way they are, or they bolt. If you have had five Axis II clients in a row, you'll need to calm down afterward.
The "by the way ..." end of a session
Once a therapeutic alliance is established, the client is usually more open and revealing. Trust has been established. Then things get complicated. There is the "open door effect." As the client leaves, they say as the door closes, "... and I forgot to tell you my wife and I had this argument, I am living in a hotel."
The door shuts. You think as a therapist. Obviously, there is resistance to discussing it; otherwise, the statement would have been the opening comment of the session. In a therapist, this tactic creates tension and curiosity.
Negative transference during effective change
The next session, you say nothing. about the out-the-door comment. The client has to raise it, otherwise as Fritz Pearl said, the gestalt psychologist, "You are pushing the river."
Never force an issue. A therapist can't force a client to talk about hot topics until countertransference has been resolved. Negative transference is when the client acts towards the therapist as a critical figure in a traumatic life. In modern psychoanalysis, transference interpretation is the heart of therapy, establishing rapport as the cure, not the process.
In couples counseling, a triad (spouses, therapist) is formed, causing resistance more than transference. One of the spouses believes the therapist is taking sides, causing counterresistance. Overcoming counterresistance in couples therapy is an art and science in helping a couple who resent a third party helping them.
How to prevent therapeutic burnout
An effective therapist can only see at most five clients a day, and if all Axis II, perhaps three. If you are a therapist, you may well disagree. Otherwise, the therapist will burn out emotionally exhausted, ignoring self-care. Many M.D. psychiatrists don't even do therapy, focusing on medication. A practical reason is diagnostic insurance coding. A 15-minute medication "consult" reimburses as much or more than a 50-minute talk session.
During graduate school, you want to learn all of this from books, but you can't. My first client in my private practice was a well-known Hollywood producer. I was 26 and intimidated, so age and experience matter. Now that I am older and have been there and done that, fame or money does not impress me in session, and I am a more effective therapist.
I also see what capitalistic "success" does to many people, so be careful what you wish for. You can't buy happiness. And life experience matters. I have been married 53 years, with kids and grandkids, and played the sandwich generation roles dealing with aging parents. I can empathize more with plights and life cycle events.
"Large talk" vs. "small talk"
In real life, most conversations are superficial. If a full-time therapist, this large-small talk changes you. The mundane and quotidian seem bland relative to therapeutic drama. It is poor manners in real life to ask highly personal questions.
Once rapport is established in therapy, I increase self-disclosure if relevant, ask more open-ended questions, use humor, don't interrupt, maintain silence and eye contact, and am an active listener given the unique confidential forum.
I, like all caregivers, try my best. Any mental health caregiver claiming 100% success is a liar or delusional. Sometimes there is a mismatch where two people simply don't connect. This is the lousy fit undermining rapport. However, sometimes things happen during therapy to break the impasse.
How I overcame a possible poor outcome
My behavior therapy was going nowhere. All attempts at interpretations fell flat. The client wasn't doing his homework and canceled the last two sessions at the last minute. To my delight and dismay, the client rescheduled the day of my early dental appointment.
The painful procedure took longer than scheduled, and I had to rush back to my office. I felt fine but looked awful from the lidocaine, causing a drooping mouth.
The client had a "funny-looking face." It was hard to describe, but it was a stigma affecting his social life and why he was depressed or angry a lot.
What happened next was remarkable. My client took one look at his suffering therapist, me, chuckled, and talked his brains out for an hour. All resistance vanished. At that moment, I was like him. He also had mild stroke-causing hemiplegia. At that particular moment, I looked like the client, and he empathized.
The client felt no therapist could ever understand how his physical appearance was affecting his emotional health. But with the situation reversed, the client saw his mirror image in me, drooling, and a special bond was formed.
The patient knew that his doctor finally understood what it was like to have a social stigma and not do anything about it. The lidocaine anesthetic was taking hours to wear off.
The breakthrough was mutually satisfying. I wrote in the client's file, "Projective identification reduces resistance," and then went back to his regular behavior therapy now that rapport had been adequately established.
It worked like a charm. If that established rapport, I guess I'll need another root canal.
Muran, J.C & Barber, J.P. (eds). (2010). The therapeutic alliance: An evidence-based guide to practice. The Guildford Press, New York.
Koener, K. and Linehan, M. (2000) Research on dialectical behavior therapy for patients with borderline personality disorder. Psychiatric Clinics of North America, Vol. 23. 1. 151-167.