Rapport: A key to treatment success

The text you provided appears to be the beginning of an article by Matthew J. Leach on the importance of rapport in treatment success. The article highlights the effects that strong therapeutic relationships may have on patient satisfaction, treatment compliance, and client outcomes. The article defines terms such as therapeutic alliance, therapeutic relationship, and patient rapport and discusses their importance in achieving positive client outcomes. The article also presents evidence from studies that support the association between good rapport and positive client outcomes. Is there anything specific you would like me to summarize or explain further?

Complementary Therapies in Clinical Practice (2005) 11, 262–265
Rapport: A key to treatment success
Matthew J. Leach
School of Health Sciences, University of South Australia, North Terrace Adelaide SA 5000, South Australia
Summary The therapeutic relationship isa concept often ignored in current
literature. As such, the importance of good patient rapport may be overlooked. To
addressthese concerns,the following paperhighlightsthe effects that strong
therapeutic relationships may have on patient satisfaction, treatment compliance
and client outcomes.Strategiesthat practitionerscan employ to facilitate the
development of good patient rapport are also discussed.
& 2005 Elsevier Ltd. All rights reserved.
Introduction
The first and most important objective of any
client–practitioner interaction is the establishment
of client rapport. Aside from facilitating commu-
nication between the practitioner and patient,
good patient rapport may also improve client
assessmentand the achievementof expected
treatmentoutcomes.1 Nonetheless,development
of the therapeutic relationship requires time and
skill.2 As the therapist’s contribution to this
alliance is often overlooked in the literature,3 the
purpose of this paper is to enlighten readers of the
importance of establishing a strong therapeutic
relationship with their clients, and to provide
practitionerswith useful strategiesto improve
client rapport in clinical practice. These skills
may also facilitate a practitioner’s ability to
develop effective working relationships with other
health care providers.4 Firstly however, an explora-
tion of the terms used to describe the therapeutic
relationship willallow readers to understand the
context in which this paper is situated.
Definitions
Many terms exist which describe the bond between
a client and practitioner. The terms most fre-
quently identified in the literature are therapeutic
alliance, therapeutic relationship and patient rap-
port. By definition, a therapeutic alliance is a
‘yconscious and active collaboration between the
patient and therapist’.3 Similarly,a therapeutic
relationship is ‘a trusting connection and rapport
established between therapist and client through
collaboration,communication,therapist empathy
and mutual understanding and respect’.4 Likewise,
patient rapport is defined as a ‘harmonious rela-
tionship’.5 As each of these terms incorporate
similar underlying themes, including collaboration,
reciprocality, parity and growth, these terms are
considered interchangeable.
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KEYWORDS
Rapport;
Therapeutic
alliance;
Therapeutic
relationship;
Clinical outcomes
1744-3881/$ - see front matter & 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ctcp.2005.05.005
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Importance
There are many reasons why practitioners should
be encouragedto develop strong therapeutic
relationshipswith their clients. On the whole,
building and maintaining patient rapport leads to
positive client outcomes.6-8 A recent survey ex-
ploring the views of 129 Connecticut Occupational
Therapistson therapeutic relationshipssupports
this claim.4 Whilst descriptive surveys are not the
most appropriate design for evaluating causal
relationships,clinical evidence is beginningto
mount that validates the association between good
rapport and positive client outcomes.
To illustrate this, a cohort study involving 354
patients in a community-basednon-profit drug
treatment programme and 223 patientsfrom a
private for-profit programme, found lower levels of
client rapport during counsellingtreatment re-
sulted in poorer treatment outcomes,including
greater cocaine use and criminality.9 Likewise,
studiesof patients with non-chronic schizophre-
nia,10 depression,11 post-traumaticstress disor-
der12 and alcoholism13 demonstratethat good
patient rapport can improve treatment outcomes.
Although these studies suggest that the develop-
ment of a strong therapeuticrelationship may
benefit patients receiving psychotherapy,the ef-
fect of good client rapport on the outcomesof
interventions in other health care fields is lacking.
Further research is therefore needed to ascertain if
changes in practitioner behaviour can ameliorate
treatment success and reduce unnecessary demand
on existing health and welfare services.
A reason why well-established therapeutic rela-
tionshipsmay contribute to improved clientout-
comesmay be explained by increased treatment
compliance.14To support this claim, mothers attend-
ing a Los Angeles children’s hospital reported greater
treatment compliance when highly satisfied with a
physician’s attitude.15 Similarly,peri-operative pa-
tients reporting a higher levelof satisfaction with
their care were more likely to take responsibility for
their decisions.16Thus, client satisfaction appears to
be a strong motivator of treatment compliance and
as such, maybe fundamental to treatment success. In
other words, good client rapport may be responsible
for improving patientsatisfaction and treatment
compliance,7 and ameliorating patient outcomes.
Even though the needs of patients are a priority in
any consultation, there are also professional implica-
tions associated with building a therapeutic alliance.
Firstly, strong therapeuticrelationshipsbetween
patientsand cliniciansmay improve the public’s
perception ofa practitionergroup.4 Secondly,by
increasing client rapport and treatment compliance,
the risk of litigation may be reduced.6,15,17
Although
this claim is speculative, Eastaugh18 and Panting19
both agree that improving client trust and commu-
nication, such as that developedthrough good
rapport, results in fewer malpractice claims. Alter-
natively, because good patient rapport is critical to
formulating adequate diagnoses,15,20 practitioners
may misdiagnoseless frequently if therapeutic
alliances are well established.
Because the practitioneris predominantly re-
sponsible for developing and maintaining client
rapport,21 the following section will highlight
several useful strategies that clinicians can employ
to strengthen therapeutic relationsand improve
client outcomes.
Application
The clinician’s behaviour and communication style
can have significant impact on the practitioner–-
client relationship. For instance, therapists who are
warm, friendly (P ¼ 0:01),affirming and under-
standing (P ¼ 0:05),demonstrate a higherthera-
peutic alliance with their patients than those who
do not manifest these abovementioned qualities.22
These attributes may also increase client compli-
ance15and improve treatment outcomes.23Another
essentialingredientin the development of the
therapeutic relationship is time.
Developing patient rapport within the first few
minutes of a consultation builds client trust24 and
minimises defensive client attitudes by blurring the
transition from ‘small talk’ to formal assess-
ment.15,25 Increasing constraintson practitioner
time, such as escalating workloads, costs, organisa-
tional and political pressure, lessen the opportunity
for practitioners to build a strong rapport with their
clients.4,26
In support of the relationship between time and
rapport, a study examining623 tape-recorded
sessions between medicalpractitioners and their
patients found consultations that were booked for
10 minutes resulted in improved client education
and more detailed patient assessmentthan ap-
pointments booked for 7.5 minutes.27 Because time
constraintscan also have a negative impacton
client outcomes,4 adequate consultation time is
therefore as important as effective communication
skills. Thus, professions that can afford the luxury
of providing consultationsof unlimited duration
may establish greater therapeutic relationships
with their clients as opposed to practitioners
constrained by time. For clinicians where time is
scarce, strategies such as providing a quiet envir-
onment; actively listening; avoiding interruptions;
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Rapport: A key to treatment success 263

and displaying non-hurried actions21 may portray to
the client that the practitioner has time to listen,
which may in turn facilitate greater disclosure of
client concerns. Whilst these strategies may assist
in developing rapportbetween practitionerand
adult clients, children may require additional
consideration.
In a study of 64 3.5-year-old children, the effects
of practitioner–child interaction on the establish-
ment of rapport were investigated.28 Children left
alone in a play room without their parent remained
with a stranger longer when the stranger greeted
the child quickly but interacted with the child for a
greater period of time. Children who were ap-
proached graduallyon the other had but only
interacted with the individual for a brief period of
time were also less likely to leave the playroom.
Thus, unlike adults, too much time spent trying to
establish rapport with a child may inversely effect
the establishment of a therapeutic alliance.28
A collaborative consultation style is also essential
to building a therapeutic relationship.3,5,14Such an
approach may empower the individualto partici-
pate in their care and allow the client to grow.5,29
Clinicians adopting a technicalor parentalrole as
opposed to a collaborative role may therefore
compromise patient rapport, respect, compliance
and treatment outcomes by invoking negative
client attitudes.26 Hence, a relationship where
the practitioner takes control and which the client
‘follows orders’ is neither conducive to patient
growth nor the development of good rapport. To
facilitate collaboration,practitionerscan take a
client centred approach; develop mutually agreed
goals with the patient;30 and involve the client’s
family in the consultation.4
Practitioners should also ensure that the client’s
right to make decisions about the choice of
treatment is retained and respected. Informed
consent is therefore criticalto establishing strong
therapeutic relationships. Equally important is the
need for effective communication.
Practitioners choosing to develop strong thera-
peutic alliances with their clients will need to
possess skills that facilitate effective communica-
tion. Skills such as listening and responding are
fundamental to the exchange of information, as is
open questioning, reflecting, paraphrasingand
summarising.30 Effective communication and opti-
mal patient–practitionerinteraction also require
the clinician to identify and respect differences in
client gender, developmentalstages, cognitive
ability, values, beliefs, priorities, culture and social
circumstance.4,24Other strategies that foster com-
munication between clinician and client are listed
in Table 1.1–7,14,20,24,30,31,33,34
Of these strategies,
client trust is paramount. It is through trust and
respect that a practitioner can enhance commu-
nication and facilitate the developmentof the
therapeutic relationship.29,31However, client trust
is not a skill that can be acquired, but an attribute
that must be developed. Nonetheless, practitioners
who are clinically competent,consistent,honest
and committed to the client32 may accelerate the
development of patient trust, and in turn, improve
client communication, rapport and outcomes.
Awareness of the signs of increasing or worsening
rapport may allow practitioners to better evaluate the
strength ofa therapeutic relationship.Signsof a
growing therapeutic alliance may be manifested by an
increased flow of conversation;the disclosure of
sensitive information;relaxed bodylanguage;in-
creased eye contact; and improvements in listening
and responding.On the other hand, poor patient
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Table 1 Practitionerstrategiesand behaviours
that improve client trust, communicationand
rapport.
Maintain: Client comfort
Confidentiality & trust
Enthusiasm
A collaborative relationship
Interest in client concerns
Objectivity
Attentiveness
Eye contact
An open posture
Avoid: Passing judgement
Jargon and technical language
An authoritarian demeanour
Interruptions
Be: Dependable
Open minded
Flexible
Reassuring & supportive
Confident
Friendly
Genuine
Warm
Sincere
Honest
Empowering
Engaging and interactive
Respectful of client wishes and
needs
Sensitive
Empathetic
Altruistic
Use: Open-ended questions
Rationales for procedures,
treatments and decisions
M.J. Leach264

rapport may present as long periods of silence; sudden
withdrawalof conversation;33 lack of eye contact;
brief responses, and defensive body language.
In cases where a therapeutic relationship fails to
develop, the practitioner may need to critically
reflect on their techniques, the environment and
the client to isolate the factors that impede the
growth of patient rapport.The practitionermay
also choose to utilise the strategies listed in Table 1
to facilitate the development of strong therapeutic
relationships.
Conclusion
The development of a strong therapeutic alliance
and the subsequent production ofpositive client
outcomes are dependent on effective communica-
tion skills, practitionerbehaviour,collaboration,
time and trust. Adopting the techniques identified
in this paper may significantlyimprove patient
health and wellbeing, and the efficiency of health
care services. The therapeutic relationship there-
fore has widespread implications for the patient,
practitioner,community and health care system.
Even so, further research is needed to evaluate the
impact that rapport has on the outcomes of
medical, nursing, complementary and allied health
interventions.
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