Have you ever wondered why some sessions with clients and therapists seem to bring about brilliant positive changes very quickly, and some just seem to plod along? Or have you ever wondered why some highly-knowledgeable and technically-excellent therapists don’t seem to get any better results in their work with clients than people whose whole therapy style seems to have no basis in science at all? It’s just possible that the answer has been staring us in the face for over 20 years.
It’s always been the case that some therapists seem to be more successful than other therapists, and people have generally believed it to be due to the style (what they call modality) of the way they work. So, for example, up until the 1960s, it’s likely that a therapist would have based their work on the theories of Freud or Jung. From the 1960s, therapists were probably using CBT (Cognitive Behavioural Therapy) or one of its many derivatives. In the 1970s there was NLP, which originally was based on successful Gestalt psychologist Fritz Perls and couples-therapist Virginia Satir – and later on hypnotherapist Milton Erickson. And later still came Solution-Focused Brief Therapy (SFBT).
All of these offered ways of working that, one way or another, proved successful. At the same time, people were seeing acupuncturists, faith healers, and homeopaths – who were also getting very successful results with some clients too. How can this be explained?
Common factors
Part of the answer comes from the work of Assay and Lambert back in 1999. They looked at four common factors that are found in psychotherapy and counselling. The factors were: techniques and model factors, expectancy and placebo effects, client variables and extra-therapeutic events, and the therapeutic relationship.
Just to put that in context, other people had tried to identify common factors previously. David Orlinsky and Kenneth Howard (1986) suggested five process variables. Grencavage and Norcross (1990) came up with 89 common factors, and grouped the 35 most common factors into five areas.
What made Assay and Lambert’s work special was that they gave a numerical value to each factor. They suggested that 40 percent of the change made by a client was due to the support network they had outside of therapy and the client’s attitude to therapy. That’s the client variables and extra-therapeutic events. The next big category was the relationship between the therapist and the client. That accounted for 30 percent of the improvement in a client. This what’s called the therapeutic alliance or the rapport built between the client and the therapist. Next, was a 15 percent improvement due to the placebo effect and the client’s own expectations of success. And lastly was the therapy techniques used by the therapist.
There are criticisms of the common factors’ idea, but, assuming it’s true or close to being true, where does that leave therapists? Firstly, it’s important that therapists understand their own modality – eg solution-focused hypnotherapy – and can use it well with clients. Without any kind of therapy, then nothing else is going to work.
Secondly, it really shows the importance of building a relationship with a client and developing that therapeutic alliance or rapport. The other two factors are, probably, outside the control of the therapist and inside the control (to a degree) of the client. Summers and Barber (2003) wrote in “Therapeutic Alliance as a Measurable Skill” that: “out of the Babel of psychotherapy models, concepts, and techniques, the therapeutic alliance stands out as a measurable phenomenon that has been shown to have a robust effect on treatment outcome”.
Therapeutic alliance
So, what makes up the therapeutic alliance or rapport and how can it be improved? The components of the therapeutic relationship are things like trust, empathy, and active listening. In addition to the personal bond, it’s important for the therapist and the client to agree on the goals of the treatment and the tasks associated with the treatment.
Carl Rogers suggested that better results were gained if a therapist was empathic, genuine (congruent), truly believed in their clients (unconditional positive regard), were engaged in the interaction, and expressed these attitudes.
Other things that have been suggested as necessary for a good therapeutic relationship are respect and caring, shared decision-making, and the ability to talk about the relationship, including any negative emotional responses and the ability to fix problems with the relationship.
Trust
Building trust can take time in a therapeutic relationship, much like any other relationship. In many ways, the therapist must allow space for the client to take the session where they want and work at the speed they feel comfortable with. Active listening helps the client to feel that they are really being listened to and the therapist understands what they are saying. And, while being friendly, the therapist should remain professional in their approach.
Empathy
Listening is crucial to understanding how a client feels. Looking for non-verbal signals can help to understand a client’s emotions. Active listening can be used to clarify what a client is saying. Being empathic means that the therapist can share (even if for only a short time) the feelings that a client has. This can help the therapist to identify what a client needs to help them.
Active listening
Active listening can be summarized as the three ‘As’, which stand for attitude, attention, and adjustment. When listening to a client, it’s important to have an open mind and respect for the client – a positive attitude. It’s hard to listen to someone without paying attention. Adjustment is all about going with the flow and adapting to what the client is saying and where they are taking the conversation.
A client can tell that the therapist is actively listening to them from their body language. Things to bear in mind when listening to clients are:
- Smiling and head nods help affirm that the therapist is listening.
- Eye contact can be used to coordinate who speaks, and it shows interest in the client.
- Leaning forward or tilting your head to one side indicates attention to what’s being said.
- Mirroring (although be careful with this!) a client’s body language indicates that you are being attentive to what the client says.
- Avoiding any form of distraction (eg looking at the clock, fidgeting, etc) indicates that the therapist is paying attention.
- Vocal but non-verbal signals, like ‘aha’, ‘mmm’, and ‘oh’, can encourage a client to continue speaking.
Things for the therapist to say when working with a client include:
- Asking relevant questions – this helps to clarify what the client has said, and it shows that the therapist has been paying attention.
- Reflecting, ie repeating or paraphrasing what the speaker has said – again, this shows the therapist is trying to understand what the client is trying to say.
- Clarification usually involves the use of open questions – this allows the client to expand on certain points as necessary.
- Summarization – this allows the therapist to use the client’s words to put in order the main points of what the client has said.
Rapport
So, let’s look at rapport in more detail. Rapport is defined as a relationship of mutual understanding, or trust and agreement between people.
Rapport building is achieving mutual trust and understanding between two or more people that leads to deep listening, meaningful conversations, and fulfilling relationships where everyone involved benefits.
Wikipedia tells us that there are a number of techniques that are supposed to be beneficial in building rapport such as: matching your body language (eg posture, gesture, etc); indicating attentiveness through maintaining eye contact; and matching tempo, terminology, and breathing rhythm.
In conversation, some verbal behaviours that are associated with increased rapport are: the use of positivity (positive ‘face management’); sharing personal information of gradually increasing intimacy (self-disclosure); and by referring to shared interests or experiences.
But is rapport that important? Isn’t it just a nice-to-have part of therapy? The answer is a definite YES – it is important! As we saw earlier, the rapport between a therapist and a client is more important than the treatment that’s actually delivered!
Conclusion
Rapport is behind the therapeutic alliance. And the therapeutic alliance has a massive effect on how well clients make progress. Building rapport between the therapist and the client is extremely important in helping any client to achieve their goals and should not be ignored by the therapist or the client as a very important part of the therapy process.
Written by Trevor Eddolls, Solution Focused Hypnotherapist, Specialist Trainer and NCH Supervisor.