What makes therapy “work” really depends on several key elements; there is, unsurprisingly, no simple answer here. Reflecting upon my work as a psychologist, I find that the most successful outcomes hinge on the therapeutic relationship, or the rapport, between the clinician and the patient. Rapport involves a sense of trust, understanding, respect, and empathy. It underlies everything else a therapist does: when a patient feels a sense of genuine connection with the therapist, and when the therapist can meet a patient on a level of genuine understanding—only then will any potential treatment I suggest have an impact. Only when the rapport is there can a patient truly begin the healing process. As I’ve grown as a therapist and worked with patients in a variety of settings, helping them with a range of presenting problems, I’ve become convinced that rapport is the foundation of therapy; everything else follows from there.
So far, I have talked about rapport as if it’s a thing that naturally flourishes between every therapist and every patient. But the truth is that from the initial contact with a patient onwards, it’s my duty as a therapist to approach each patient from a place of compassion and empathy while we discuss the issues to be addressed in treatment. And this can be a very delicate, gradual process. For example, during the initial evaluation, I need to simultaneously gather enough information about the patient to understand them as a whole (which means a sense both of their problems and their talents, their vices and their virtues and everything in between) while also cultivating a warm, empathic environment where they can feel free to discuss things that perhaps nobody else has ever heard.
Trying to gather a lot of information in a limited amount of time without letting this impact the conveyance of understanding, care, and empathy—to be honest, it’s a tricky balance to strike. One way that I manage it in my own work is that I emphasize to my patients the collaborative nature of therapy. I want them to understand that I may be the expert in treatment, but they are the experts on themselves, and their lifetime of “expertise” is always welcome in developing and revising the treatment plan.
The same applies to a patient’s decision to keep or skip appointments. Patients who feel connected to and understood by me as their therapist are more likely to come back to my office, more likely to open up to me, and more likely to seek further understanding and insight. Why? Because they trust that I will be able to take the pain of disclosure, of self-examination, and help them channel it into something useful, something healing.
After all, unless my patient is on board with the treatment plan I have in mind, the likelihood of their getting better is pretty slim. A strong therapeutic connection helps the patient overcome that initial hesitation. This hesitation can be based on fear, worry, concern, frustration, or even disbelief that such step in the treatment will actually help—all legitimate emotions. As a therapist, it’s my job to encourage my patients to keep moving forward and continue progressing. It’s true that I have “tricks” and techniques at my disposal to help them along, but even if I use all the tricks in the world, the two of us will get nowhere without mutual trust and understanding.
With a strong rapport, in contrast, the patient believes the therapist understands their problem and has the expertise to help them feel better. As a result, the patient will be more likely to try practicing these skills on his/her own between sessions—even if they are hesitant at first, they know that they are being held accountable by someone who cares for them (me) and that gives them the motivation to persevere. It’s my rapport with them which allows a patient to grit their teeth and try various strategies to better cope with their distress, even when those strategies seem painful or difficult. It matters to them to make that effort because it matters to me—and because they know that they matter to me as well.
Finally, I cannot create an environment that feels authentically caring, safe, and comfortable unless I am authentic myself. My patients will always have a sense of who I am as a human being, not just as a “professional,”—meaning my style of interaction, my sense of humor, and my insistence on how deeply cared for each patient truly is. Of course, it’s important to maintain professional conduct. But I have learned, over time, the value of allowing patients to have a sense of me as a person just like them. This fosters a genuine relationship. It furthers the development of trust. Ultimately, it increases the chances for a successful therapeutic outcome— in other words, the chance that therapy will work.
There are no shortcuts, no techniques, no tricks to developing that kind of connection with a patient. Small moments of kindness, a willingness to meet the patient as an equal, a concerted effort to invite their perspectives on their own lives while also offering your own—it’s out of gestures like these that rapport lives and dies. Ultimately, the same goes for the therapy which rapport anchors.
If you have any questions about how therapy works, get in touch with me on Twitter @DrThacher_USP!