Back to School: The ABCs of Therapeutic Rapport

rapport during therapyLaura Wilkie, an experienced and highly regarded occupational therapist in the area, recently wrote about therapeutic rapport and how it can by the key to rehabilitation after a serious injury. Wilkie is the Director of Medical Outreach at Greg Monforton & Partners. We are excited to share her advice on therapeutic rapport below.

A key tenet in a successful rehabilitation journey for any patient and client, regardless of discipline, is Therapeutic Rapport. It is the foundation for trust. It allows a connection to exist. Without rapport and trust the chance of a productive therapeutic relationship is minimal. Building rapport is not up to the client, rather it is up to us as clinicians to develop. To be successful as clinicians we must implement the ABC’s of Therapeutic Rapport.

Let me take you back to the beginning …

I was 25 and looking adulthood in the eye. I was finally out of the classroom, and onto the last leg of the post-secondary journey  my final internship. As an Occupational Therapy Intern, it was about what was taught in school. It was all business  getting the patient up, out of bed, and into therapy. I approached tasks with a “can’t take no for an answer” attitude. As I quickly learnt, getting patients to buy into this was a challenge.

I struggled with my patients  and my patience  because most were “not feeling up to it right now”, “too tired” or in “too much pain.” What was their problem? Didn’t they know it was about productivity measures? Me earning my stripes? Proving myself to the team? Why couldn’t they follow the doctors’ orders and cooperate, get up and get through these treatment sessions? I was frustrated, and it showed.

Then it happened  a moment that I didn’t realize at the time would shape me as a person, and my career in the years to come. A medical emergency landed me under the knife and in hospital for 2-weeks, and on bed rest for an additional 4-weeks.

I learnt in those weeks what if felt like to be scared  truly scared for my health and my future. I experienced physical and emotional weakness beyond my control. I was on the receiving end of others’ opinions and expectations on my ability  opinions and expectations that in the moment seem so outrageous, unrealistic, and out of my reach.

I learnt what pain  real physical pain  felt like.

And I discovered the tie of emotion to physical injury and illness. They coexist, cannot be separated, you cannot have one without the other.

What was I really learning in those moments? What gift had I been handed?

Eight-weeks later I received my all clear. I returned to my internship knowing I was physically weaker, but I had to finish this chapter to move forward.

I grabbed my daily sheet, and went to see my first patient  a gentleman who was only a few days post quadruple bypass, with a lower extremity coronary artery bypass graph. (His bypass vessels were harvested from his lower extremity and an incision ran along the inside of his leg, from mid-calf to mid thigh).  I reviewed with the gentleman the physicians order for an OT to work on “ADL’s and functional transfers “. He politely declined, saying he felt too weak and painful – and didn’t see the need for therapy. 

I began to enter my typical modus operandi … but … stopped mid-sentence. I found myself reflecting in that moment on what I had been through the weeks prior. There was no way I would have wanted to cooperate with me.

I knew the importance of therapy to strengthen and promote normal activity after open heart surgery – and also knew the risk of depression and risk of decline if activity is not resumed.  Avoidance of therapy and getting up and doing for oneself were yellow flags to those concerns. I needed to retool my approach.

I asked the gentleman if I could just spend a few moments with him; that I wanted to learn more about what he had been through. I emphasized that we didn’t have to do more during our session than he was up to. I knew too well what it felt like to be weak and sore. He welcomed me to stay.

We began chatting. He shared his pre-surgical experiences including the fear he had faced. He opened up about his fear that he “wouldn’t make it” and that he would be a “widow-maker.” He had been terrified of the possibility that he would leave his wife behind. Even though he survived surgery, he now feared that he would not be able to be the person he had been before  puttering around the home, playing with his grandchildren and dancing again with his wife of 57 years. He feared activity.

The emotion of his experience sounded, and felt, too familiar. He was where I had been and I realized I understood.  He was expressing emotion that was true to my experience. I found myself truly in that moment with him. Through conversation he began to see the purpose of activity, finding new methods and strategies. We discussed fears and anticipated limits. Together we were able to review the reality of ability, and identify and discredit unrealistic fears. With the provision of reassurance he moved into the activity component of our session with confidence in  himself, and me.

By the end of the session, he had achieved all of the goals planned and he had done more for himself in one hour than he had done in all of the previous weeks combined. He had new found confidence in his ability and strength. With the help of OT strategies he had accomplished, for the first time, what he had set out to do each of the previous three days  shave and wash up so he could feel presentable for his wife who was to visit in the afternoon.

As I prepared to leave his room, he thanked me for listening and showing patience, and for my understanding and compassion. I did not realize until some years later but this was a turning point – it was the birth of the new therapeutic me.

Therapeutic Rapport is a crucial piece of successful therapeutic outcomes. It can be found in each us, we just need to know how to use it. 

Academia does its best to educate us on the practical applications of our respective disciplines. The human aspect of how we share and put into practice our knowledge is left to us alone. It cannot be memorized from a textbook.

To improve the probability of success in therapy programming, clinicians need to realize that they are not simply a pipeline or pathway existing solely to move information forward. Clinicians are in fact a crucial tool in the therapy process. Once this is realized clinical effectiveness increases markedly.

Our attitudes and how we present ourselves to our clients is paramount to development of therapeutic rapport – and necessary for successful therapy outcomes. This starts at the first hello. To trust us, our clients need to feel safe in our environment – both physical and emotionally. We have to remember and appreciate that our environment is foreign to our clients, and often looks quite intimidating and medical.

Over my clinical career I have learnt the importance of therapeutic trust and the human connection in the building of rapport and thus successful therapeutic outcomes. I have seen far too often others fail in their success as clinicians because of the absence of connection. To develop this trust in a clinical setting, therapists must realize they need to develop and implement the ABC’s of Therapeutic Rapport. Our success as clinicians, and the clients success as a patients is dependent on these ABC’s:

  • therapeutic listening skills, and being an active listener – not just hearing the patient, but listening and attending to what someone is saying
  • being present in the moment with the client or patient – our use of self through both verbal and non verbal communication, making eye contact, and engaging in the conversation
  • make the human connection – connect with what they are feeling, what drives them; this is found by taking the time to learn a bit about the clients as humans and as individuals – what drives them is what is important – asking for this information and showing interest will feed their trust and connection with you, and allow the setting of therapeutic goals that are clinically relevant, and meaningful to the clients – using this approach the clients will not only buy into the therapy process, but they will own it

Making a connection.

During that one hour in that gentleman’s room back in March of 1997, I let someone I didn’t know feel safe, and be safe. Feeling safe allowed him to voice his fears. I was an active listener that day  seeing the fear on his face and holding his gaze as he opened himself up to raw emotion. I began to learn what made him tick and what was truly important to him I was honest with him and myself, and this allowed me to be in that moment with him. I allowed him a human connection, and through that connection he trusted. With the trust he gave back. He allowed me to engage him in therapeutic tasks that he had previously declined. By the end of the session, he had achieved all of the activities I had planned. He had done more for himself in one hour than he had done in all of the previous weeks combined.

I realize now that during that time I was laying the foundation for fundamental skills necessary to allow me to be a successful clinician. 

I have carried this moment forward with me into every therapeutic relationship over the past two decades.  And have used this experience as the foundation for my approach to clinical practice. To this day I have continue to hone these skills in each and every relationship I develop. 


The ABC’s of Therapeutic Rapport

Actively listening

Being present in the moment

Connecting with what others are feeling, with the human in front of you