Overcoming Barriers to The Therapeutic Alliance

By J.P. Foster 08/27/15

Four essential elements in establishing rapport with substance abuse clients.

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For a variety of reasons, therapists often confront barriers to the formation of a therapeutic alliance with patients with addictive disorders. One major factor is that many addiction treatment episodes are initiated by somebody other than the patient—for example judges, employers or family members. Another big issue is that because addiction is so highly stigmatized, patients can present for treatment with feelings of anger or shame that can interfere with the therapist-patient connection. Addiction therapist J.P. Foster understands the challenges and offers four key elements that can help overcome barriers to connecting with patients…Dr. Richard Juman

Have you ever walked out of a therapist’s office thinking, “That was a waste of time!” or “What the hell was that? What just happened?” How about the therapist who talks endlessly, not allowing you to get a word in edgewise? Or the therapists who continually talk about themselves and their accomplishments? One thinks: “Yes, I see your degrees on the wall and the letters after your name on your business card, and how magnificent a therapist you are. Can we get back to me?” I recently had a family member approach me about a referral for a therapist.

“What are you looking for in a therapist?” I asked. 

“I don’t know. Someone to help me solve my problems.”  

I chuckled inside, and then explained that good therapists don’t jump in and solve a client’s problems, but rather, help facilitate changes within the client through introspective questioning and insightful feedback. One of the core mechanisms for change is the development of a solid treatment alliance between therapist and client. It’s difficult, if not impossible, for clients to move forward in the absence of a solid relationship between the client and therapist. Important as it is, it’s not unusual for clients in addiction treatment to struggle to find a therapist that “fits.” It can be like dating in high school or college. You go out a few times, like the person, but there isn’t that emotional connection. Rapport is a critical relational element that begins almost immediately and continues throughout the therapy process.  

Rapport is the relational interaction between a client and therapist, opening doors to emotional processing, healing, feedback and intrapersonal growth. Rapport is an unseen, unwritten connection made between a client and therapist. Often, rapport is the intangible catalyst of change within individuals, an avenue for vulnerability and intrapersonal insight, growth and hopefully change. 

Rapport is a multifaceted aspect of life and not limited to therapeutic relationships. Rapport can be seen in the way we interact within our families, with our children, among our closest friends, with colleagues and employees, and is also a crucial element in leadership and team building. Every relationship a person is involved in is impacted by rapport, whether it’s waiting in line at the grocery store, attempting to merge onto a highway in rush hour traffic, or walking down a busy street. Therapeutic rapport is a building block where intrapersonal insights and changes begin taking place. Rapport is a catalyst that enables a counselor to push a client beyond their comfort zone, striving for lasting changes and insightful breakthroughs. 

The difficult aspect of developing rapport with clients is the short-term nature of many counseling styles. With managed care companies determining the number of sessions covered in therapy, sometimes the focus isn’t on therapeutic, long-term gains, but rather short-term problem solving strategies. Developing rapport with a client who only sees a therapist a handful of times can be difficult, especially if there has to be a focus on crisis intervention throughout the therapeutic process.

Working in an agency providing Intensive Outpatient (IOP) substance misuse treatment, I work with clients from the moment they walk into the office for their intake assessment all the way through the discharge planning process. Hopefully, the first interaction with a potential client is the time that the first spark of an initial rapport is built. At this point, it’s a handshake, a smile, a warm greeting. Non-verbal communication must convey understanding, compassion, acceptance and trust (aspects I’ll come back to in a moment). In my case, I sit with an open posture, asking informal questions, gaining general information about the client.  

“What’s going on? What brings you in for an assessment today?”  

“What prompted you to seek treatment at this point? Why now?”

I’m gently probing in response to what I’m hearing.

"I see, can you tell me more about that? What led to your increased use a couple of years ago?”

I’m expressing my understanding of the client’s existential situation.

“That must have been a difficult adjustment, who did you turn to for support?”  

“Wow, that sounds emotionally painful. I’m sure others would have drank under those circumstances, too.”

I’m trying to get a general sense of the kind of life my patient has led.

“Tell me, what was it like growing up in your home? Were you parents supportive?”

“When you were a child, who made you feel loved?”

Hopefully, the nature of the initial dialog is the opening for developing rapport.  

Although the content of the initial questions is key, I think that both verbal and non-verbal communication are catalysts in demonstrating care, concern and compassion. What are my first inklings that I’m starting to develop a positive therapeutic alliance with a client? A prominent indicator that I’m developing rapport with a potential client are responses that say to me:

“I can’t believe I told you that! I’ve never told that to anyone!”  

“You know, I’ve never talked about this to anyone!”  

“This is so weird, I can’t believe that I’m talking about this.”

The expressions of openness and vulnerability are important clues that an environment where emotional healing can occur is present. From the therapist’s vantage point, the privilege of someone sharing deeply personal information must be reciprocated back through empathy and compassion, ensuring trust and safety.

Rapport is developed through understanding, compassion, acceptance and trust. Oftentimes, working with individuals with substance use disorders, shame and guilt are two of the more significant emotions the individual experiences. Walking into treatment can be one of the most anxiety-provoking experiences someone goes through. One question I’m often asked by new clients is, “Are you an addict?” or “Are you in recovery?” I generally avoid directly answering these, usually turning the questions back to the individual. A deeper meaning behind these questions is “Can you understand how I feel and what I’m going through?” This is a critical juncture where a clinician can develop rapport through non-judgmental language, using a soft tone, conveying respect and understanding, rather than condemning. 

Demonstrating compassion for the challenges that a client is confronted by is a second aspect in developing rapport. One of the key skills I embrace on a daily basis is empathy (at least I try, given that I’m human and some days I’m better at this than others). This is a therapeutic endeavor that can be quite difficult with challenging or combative clients. I find myself continually reverting to a mindset of compassion when dealing with these individuals, which helps me remain grounded. Compassion helps me move back to a place of rapport. Rapport through compassion unlocks doors that enable clients to continue to grow. Recently, I had a person say to me, “You probably think I’m crazy, right?” A simple, non-judgmental response that reassured belief in the client helped the therapeutic process along. “Sounds to me like you did the best you could under the circumstances, with the skills you had at the time.” As the session progressed, the individual continued to repeat, “I can’t believe I’m telling you this!” Compassionate rapport building evokes continued cathartic moments and processes.

A third critical aspect of rapport development is acceptance—the ability to meet the client right where they are, without judgment. Acceptance leads to rapport by allowing a client to use self-determination in how therapy sessions proceed. Working with individual clients, I explain to them the theory (psycho-analytical) I incorporate in my practice and how this is a slower therapeutic process. I ask clients what goals they have for therapy and what they would like to work on or discover about themselves. Allowing a client to determine the course of treatment is a clear demonstration of the fact that you accept them where they are. Once a person came up to me, aggravated by their individual counselor and the topics they were discussing in their sessions. The individual complained about the counselor’s style and approach, which never took into account what the client wanted to address or the pace the client wanted to proceed in addressing their issues. Acceptance of a client and where they are and where they want to go, closes the distance in the relationship, further developing rapport.

Finally, trust within the therapeutic relationship provides safety and security, further developing rapport. Trust is the confidential factor encompassing understanding, compassion, and acceptance, providing the individual with a safe environment to process painful (uncomfortable) emotions and memories. The trust and safety in a therapy session allow healing to take place. Often, clients with a substance use disorder are survivors of past traumas. Vulnerability and trust develop slowly over the course of the therapeutic relationship. Rapport developed between the client and therapist is based on trust and the ability for the client to become vulnerable in a safe place with someone who is dependable and respectful.

Therapy is a process of healing, facilitated through the rapport developed between a client and therapist. Rapport is generated over time, offering a client the freedom and safety to facilitate healing and change. A client who does not feel a therapist’s compassion, understanding, acceptance, and trust, may not make meaningful, lasting changes. Clients must learn to trust their instincts in working with new therapists/counselors. Remember, if there isn’t rapport, there probably isn’t a strong enough relationship to build lasting intrapersonal changes.  

There are times at which developing rapport with a particular client can be a huge struggle for me. I often get referrals for individuals who are just stepping down from detox, with many of these clients requiring a higher level of care (residential treatment) than outpatient. My line of questioning during the early portion of an assessment can either facilitate or derail the rapport-building process. When I’m too direct too quickly (“Why didn’t you go into residential treatment?” or “I think you need residential treatment!”), individuals often react defensively. When, occasionally, a client is direct enough to confront me about my questioning, I immediately recognize that my approach is interfering with the development of rapport.

Confrontation is usually an indication of the "righting reflex" or a power struggle between me and the individual. Pulling back from a direct line of questioning and acknowledging how I made them feel (defensive) is my first response in rebuilding rapport. Admitting to the client that I was too confrontational with my line of questioning often gives back a sense of control to the individual. Validating their defensiveness gives both of us an opportunity to recalibrate. Rolling with resistance (giving the individual a sense of control) can re-engage the conversation and begin establishing rapport.

Angry, defiant and bitter individuals can also present challenges for establishing rapport. Anger is often a coping mechanism for keeping others a safe distance away, or an indicator of a possible underlying trauma so my line of questioning has to respect their space and create safety. I vividly remember one client who reacted extremely defensively towards my questioning. His face became tense, his fists clinched, voice raised and eyes darted back and forth as he vocalized his disapproval of my questions. In this scenario, I had pushed too hard, too quickly. I immediately acknowledged his emotional reaction and validated his feelings. Acknowledging that my line of questioning may have been too direct, I quickly shifted to compassionate questions about times in his life where he felt he had to protect himself. Demonstrating compassion and empathy on my part helped re-establish rapport with this individual and allowed him time to process the emotions he was going through in the moment.

Well-guarded or defensive clients have also presented challenges in developing rapport. Sometimes it’s because these individuals are forced into treatment. Often, they are referred by the criminal justice system, a spouse or family member, employer or attorney. These clients may not believe that they have a problem that needs treatment. Defensiveness is their natural state because they feel forced into doing something that doesn’t seem necessary; therefore, developing rapport can be nearly impossible. They will often respond to questions with questions.

“How would that make you feel?”

“When do you go to meetings?”  

“How would you know how I feel?”  

Acknowledging their questions, validating their emotions and joining them in their frustration helps establish rapport. I rarely spend time attempting to convert the person or force them to see their problem(s) as worse than they recognize. One case, I simply continually rolled with their resistance, asking questions in a non-direct manner:

“What’s it like arguing with your parents/spouse about your drinking?”  

“When did their attitude about your drinking/using change?”  

“What else was going on in their life at that time?”  

“When did your P.O. begin cracking down with random alcohol/drug screenings?”

Throughout our continued exchange, I was able to establish rapport through validating their concerns, bypassing the need to convince them that they had a problem, and helping them understand how positive behavior changes could make their lives easier.

James P. Foster, LMSW, LCDC facilitates an Intensive Outpatient program for North Park Counseling Associates in Dallas, Texas. Mr. Foster graduated from the University of Texas at Arlington in 2012 earning an MSSW, with thesis.

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James P. Foster, LMSW, LCDC facilitates an Intensive Outpatient program for North Park Counseling Associates in Dallas, Texas. Mr. Foster graduated from the University of Texas at Arlington in 2012 earning an MSSW. You can find him on Linkedin.

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