Unleashing the power of rapport: Transform your therapy sessions

Hey there, everybody, and welcome to this video on developing rapport and secure attachment. I'm your host, Dr. Donnelly Snipes. In this video, we're going to discuss how displaying secure attachment behaviors can help clinicians develop rapport and create a sense of safety and connection with the client. What is secure attachment? I think most of us are familiar with this, but we'll just review it real quick. Attachment trauma is at the root of a lot of addiction and mental health issues. Many people have never had a secure attachment, or if they did, that attachment may be long gone. Creating a secure attachment in the therapy room allows people to feel safe so they can be authentic and vulnerable without fear of judgment or abandonment. What is rapport? Well, that's that sense of safety, connection, and trustworthiness. We can all think of people in our life with whom we have rapport, and we feel like they understand us, they get us, they're not judging us. And then there's other people with whom we don't have rapport. And it feels like we're kind of trying to pull teeth every time we try to connect or communicate. Think about how a lack of rapport impacts our ability to do a thorough assessment. I mean, really, if someone is meeting us for the first time and they don't feel safe, they don't feel secure, they are worried about whether they're being judged, so they're not going to be authentic. It's really going to askew our assessment results. We need to make sure that one of the first things we do when people come into our clinic or connect with us online is to develop rapport. Introduce yourself, make a little bit of small talk, get to know who they are as a human being so they don't feel like just another number, so they actually can perceive that you care about them. The same thing is true for treatment. If there's not a good rapport between the two of you, then you're going to have difficulty in treatment. Treatment. And I see this a lot, and it breaks my heart where somebody starts talking to me. They're like, doc Snipes. I really don't like the way things are going with my therapist, but I don't feel like I can tell them or I'm afraid to tell them. That's not okay. That is a lack of rapport. It's really important that clients feel like they can tell you what's on their mind. You may not like it, but they can tell you. And it's a safe place for them to express their feelings, thoughts, wants, and needs. Developing rapport means meeting the person or the client where they are at emotionally, physically, and helping them feel confident that you're there to help them achieve their goals. In order to develop that rapport, we really want to demonstrate secure attachment behaviors and we've talked about these in other videos. Consistency in your presence and your behaviors, both within session and between sessions. So if they come in today and they meet you and you're Jekyll, when they come back next week to meet you, hopefully you'll be Jekyll again and not hide. You want to be consistent between sessions. You also want to be consistent within sessions and not be attentive the first half and then daydreaming the second, or listening and paraphrasing the first half and directing and authoritative the second half. Be consistent. A stands for acceptance and unconditional positive regard. It is so crucial that we provide people with a sense of acceptance for who they are. We value them as an individual, as a human being. We may not like all their behaviors, we may not like all their opinions, but that doesn't matter. We value them because they are a human being. R stands for responsiveness. And that means to their emotions, their questions, and their problems when they start feeling an emotion. A lot of the people we work with don't have a really high emotional intelligence and that doesn't mean they're dumb at all. It means that they are not comfortable and aware of their emotions, what causes them and how to deal with them. So we need to be responsive to their emotions. If we notice that they're starting to fidget in their seat, we can identify that and say, hey, it seems like you're starting to feel a little uneasy or antsy. You want to tell me what that's about? We can start talking with them about signs that they're feeling certain feelings so they can start becoming more mindful and, and develop the ability to identify feelings within themselves before it becomes an all out overwhelming emotion. We want to respond to their questions and it could be questions about what's your degree? It could be questions about why are you making me do this? It could be questions about hey doc, what can I do in order to feel better? But we want to respond. If we don't know the answer, that's okay. And that's one of the hardest things for beginning clinicians to learn, is to be able to say, I don't know. That's a really good question. I'll get back to you. And it's important that if we say, I will do some research and get back to you. Guess what? We get back to them and we need to be responsive to their problems. If they come in and they tell us that they're having problems in these four areas, for example, we need to take them all seriously and understand that for that person at that point in time, those are problems. And even if we don't perceive it as a problem, we need to recognize how they perceive it and be responsive to their concerns. We also need to be responsive to their concerns about our treatment style. And I know I said that earlier, but it is so important. Too often people do not feel empowered to tell their therapist, hey, this ain't working. Or no, you, you suggested that I do that, but I have no desire to start journaling or something. Okay? I would much rather a client tell me what they're not going to do so we can figure out what they can do instead than just be resistant to it. Just not do it. And if you find that you've got a client who is regularly not doing things, that's communication. That is them saying, either I don't understand why it's important. I don't have the skills to do it. I am afraid to do it for some reason. We need to explore what that means when they don't do what we want to do. And I don't like the term resistance because it has been pathologized quite a bit to mean or to be interpreted as the client is willfully being oppositional and they are not. They are acting and reacting from their point of view, and we need to do a better job of understanding that. And that all goes into responsiveness. Behavior is communication. They're doing behaviors we don't understand. Let's talk about it so we can understand what they're communicating and figure out how to deal with it. E stands for empathy with limited self disclosure. Empathy is so important because a lot of the people that we work with have been told that their feelings don't matter or that their feelings are overwhelming or a lot of other things. And it's important that we empathize with them and go, oh my gosh, that is just devastating to hear, or I can't. I hear how enraged you must must have been. Even if we wouldn't necessarily have reacted the same way, we want to empathize with how they felt at that time. And remember their feelings are based on their lifetime of experiences, their schema, and their expectancies. So empathize with them from their point of view. I had a professor one time tell us the difference between sympathy and empathy. With sympathy, there's somebody stuck down in the bottom of a really cold, dark well and they can't get out. And we sympathize with them by looking over the edge going, hey, must be cold and dark down there. I'm sorry, you know, here, listen to you if you want, but we don't really get it. We're not seeing it from their point of view, we're seeing it from the top down. Empathy is strapping on rappelling gear and getting down into that well with them so we can experience to a certain degree what it's like to be stuck in that well. Now with the repelling gear, we can get back out. We're not stuck down there with them, but it is helpful to see it from their perspective. When you are working with small children, it can be really helpful to literally get down on their level, to see the world the way they see it, to see how huge people look when they're towering over them. It's all about perspective and empathizing with people based on their perspective and is important. Most of us in our culture have not learned the skill. So their friends, their family, their co workers, whomever, have probably been reacting to situations based on their own points of view. And if that differs from the client's point of view, which it usually does, then the client may feel invalidated. We want to provide limited self disclosure. When we're empathizing, we can say, wow, that must have been devastating. I went through something similar, blah, blah, you don't want to share too much. It's not a therapy session about you. It's not time to bond over a shared trauma or something. But it can be helpful for the client to know that you're human, that you have gone through trials and difficult times in your life because they can see that you have emerged theoretically healthy. And we want to provide safety in a supportive environment. We don't want the people that we're working with to fear that they're going to overwhelm us if they show us their true selves or their emotions. We don't want them to fear that we're going to abandon them. We don't want them to fear that we're going to commit them to a psych hospital. We need to be very clear, of course, about the limits of confidentiality and what steps we have to take in the event they are an imminent threat to themselves or someone else. But it's so important, especially these days, to really clarify with the person what imminent threat means so they don't feel nervous or afraid to say, yeah, I've been feeling kind of suicidal lately. Okay, let's talk about what that means. What does that look like? That is very different than an overt threat of self injury. If people are prohibited or fearful of talking about things, whatever those things are that they fear rejection or committal or something else, then those things are not going to get resolved and they're probably going to get worse. We need to be open. One of the things I do with my clients is I encourage them at the end of a session to tell me what they got out of the session and what was one thing that seemed to really be helpful for them that day. And if it was a bad session, we all have them. If it was a bad session, we just didn't feel. I don't feel like we really connected. I might ask them or say something to them like, you know, it felt like we were really struggling to connect. Today I'm wondering what, what I could do differently or what we could do differently next week in order to make more progress, in order to feel like we're more connected. That's not critical of the client. That is acknowledging, hey, I was feeling it too. It didn't feel like we were making a lot of progress. Let's talk about it instead of, well, let's just assume it's all your fault and move on. No, that's not it at all. And some days it's not going to be anything in particular that you do or don't do. You're just not going to be on the same wavelength. That's okay, too. Opening that door and discussing those things, telling the, the person, hey, it's okay to tell me if you don't feel like we're connecting is so liberating. For a lot of clients who are so afraid of being critical, they've never been allowed many cases to be critical or provide constructive feedback to anybody else in their relationships without fear of retribution. It takes a while for them to get comfortable with this, which is why, again, I open that door at the end of every session, what went well? And sometimes I'll say, what do you think we could do differently next time? That would make it go even better. It doesn't. Well, that's a good place to start, in my opinion, in order to empower clients to start feeling like they have a say in what's going on with their treatment. So think about what each of these different behaviors would look like in a session with a client. Consistency in presence and behaviors might look like not checking your phone, not answering the phone, not answering the door, making eye contact, not daydreaming, making good non verbal communication. All of those can be helpful between sessions. You know when they come back the next day, greeting them, knowing their name, being consistently glad to see them. You're going to have some clients that you really like seeing more than others. That's normal. But it is important that we're consistent in our presence with them and acknowledge that they're valuable and they're important. Providing acceptance and unconditional positive regard. Continue to make eye contact. Continue to communicate with them. Pay attention to your non verbals. If somebody says something you don't like and your non verbal is, that's going to scream volumes to them. Make sure that you are communicating what's going on with your non verbals if you need to, but you want to provide an environment that's accepting. And if you're having a bad day that day or one of the things I recommend doing, I do it is if you're having a bad day or you didn't sleep well, just bring that up in the initial small talk you're making with the client. So they know if you start yawning in session, it's not that you're, they're boring you, it's your kid kept you up all night. Okay? Be responsive to their emotions, questions and problems. Ask questions when they ask a question or present an issue. Be curious. Be involved. Be invested in what's going on. Don't start lecturing them. Instead, try to help them solve their problems. Use some Socratic questioning. You know, sometimes it's going to be a straightforward question they have for you and you can give a straightforward answer back. But it's important to not minimize their concerns or their problems. Showing empathy with limited self disclosure. I already kind of talked about what that might look like and sometimes limited self disclosure may just be be involved with the decor you have in your office. If you've got pictures of your kids and your pets and what have you on your desk, then that communicates to the client about some of the things that are important to you. It can be helpful to develop rapport by finding a couple of things or at least one thing that the two of you have in common. If you are, I mean, you're both humans. That's, that's good. You're both children of somebody. That's another thing that you can bond over. There are also other hobbies, for example, or animals. If they have pets. If they have kids. Take an interest in Their kids learn their names. It doesn't mean you're going to be talking about their kids all the time, but it makes people feel important and safe when you take an interest in their life and providing safety in a supportive environment. Ask the client, go back over those same things and think about what are some common mistakes clinicians make that destroy rapport? Think about things people have done, whether it's been teachers or bosses or therapists that have made you feel like they didn't really care that you didn't have rapport or connection. Behaviors. To help people feel safe in session, the mnemonic is ace, Ask, Collaborate and Empower. Instead of telling them what you're going to do to help them feel safer, ask them what would help you feel safer or more comfortable in this situation, in this setting. What are your concerns about therapy, about your diagnosis, about treatment? What are your concerns? What are their. What are your goals for treatment? I know, that's radical, isn't it? Asking a person what their goals are instead of telling them what their goals are. Who knew? Yes, we need to ask them what their goals are for therapy. And another one of those radical groundbreaking questions. What does the person think would or wouldn't help them? Wow. We're empowering them to start giving us information so we're not just like spitballing, throwing different techniques at them, trying to figure out what's going to work. They probably have an idea, they may have already tried some things and they know what doesn't work. Or they may have tried some things that worked a little bit and they want to build on those. Well, great. So ask. The more you ask, the more you consult on the person as an expert on themselves, the more empowered and the safer they will feel. They've lived in their own skin for however many years they've been alive. They are the expert on themselves. You're the expert on addiction, on mental health issues, on cognitive behavioral techniques. They're the expert on themselves. What works, what might need to be adjusted a little bit to make techniques work for them. Bring them in, collaborate with them. Which takes us down to collaborate with them and figure out what is going to work for them at this time. If you are working with somebody and you think that they would benefit from residential, but they are just not in a place where they were. They are ready, willing or able to do residential. Okie dokie. What would work or what would you be willing to do instead? If they don't want to go to 12 step meetings. Okay, what would work for you instead? I'm not going to lecture somebody about what they should be doing or shouldn't be doing. What I want to know is, what will you do? And if there's something that I think is important that you won't do, tell me why you won't do it. Help me understand what's motivating that, and let's see if we can find something you can do instead. We're working together. I may give somebody a assignment, a technique, whatever you want to call it to do between sessions, they come back and I'm going to talk to them. How well, how did that work? And if they say it worked, great, doc, wonderful, keep doing it. But if they come back and they say, well, when I remembered to use it, it worked pretty well, but I just had a hard time remembering to use it, great, thank you for that information. Let's figure out how to help you remember to use it. So I'm getting information from the person about what parts of that intervention worked and what needs to be adjusted for them, what needs to be individualized for them. And then we're going to empower with synergy and win wins. I regularly tell people that, at least in the first session, they are the expert on themselves. And I do tell them that in those words because I don't want them to have that white coat fear or think that I am going to do something magical or mystical and fix them. No, they're the expert on them. I know I have a lot of book learning and I can help them apply it. I can be a catalyst for their change or to help them implement these changes. But I can't tell them exactly what's necessarily going to work for them at this time. So we need to synergize. We need to work together. They tell me how they're feeling, what's working, what's not, and I adjust. And we want to create win wins. Sometimes, especially if you're working with involuntary clients, they don't have any intention of getting better or stopping using or whatever, and that's okay. And that's another radical concept here. I'm not going to force it down their throat that they need to get sober and stay clean for the rest of their life. If they don't want to, they ain't gonna. So let's create a win win. You, the client, want to be free from counseling whoever's making you come. You want to satisfy their conditions so you can be done with it. All right, in order for me to sign your discharge papers, these are the four things that need to happen. You know, you need to attend when you're here, you need to be actively engaged, you need to be clean and sober when you're here. And okay, so three things. And that creates a win win. I'm saying I'm not going to tell you how to live your life because you're the only one who can make that choice. I am here to try to help you overcome whatever this current obstacle is. And with involuntary referrals, it's usually probation or some sort of a case plan or something else. In terms of communication, basic active listening, reflect what you hear from them, not only from their words, but also from their non verbals. If they're telling you, oh yeah, it's been a great week, those non verbals are not jiving with their words. And it's important to say something like, I hear you telling me that it's been a great week, but it doesn't seem to look that way. And I, I sense there's something that's weighing heavy on you. So I'm reflecting what I'm hearing and seeing from them. Clarifying is important. We hear people's words. Hopefully you hear all of their words, but you don't necessarily know that you understood what they said, which is why paraphrasing is so important. And sometimes people get on a roll and they're just so excited and they're talking and talking and talking. It's important to periodically stop and say, okay, I just want to make sure that I'm understanding what we're talking about here, everything that you're telling me, because it's important for me to understand where you're coming from. This is what I've heard you say so far. Is that accurate? Am I understanding you correctly? And they will say yes or they will say no. You kind of missed the point. All right, well clarify it for me. Stopping and periodically clarifying not only helps you make sure you are understanding what's being said, but it also stops the the person and has them reflect on what they're saying to make sure that they understand what they're communicating. They're doing some reflection when they are trying to restate it to you. And that may provide them clarity without you having to do anything. Focus or direct to a particular topic. Focus on one thing at a time. And I've had people come in who just come. They have a litany of issues that they want to handle. Or when I work with people who are in a manic or hypomanic episode, they may be all over the place that's okay. I have a whiteboard in my office and I will just start writing things down on that whiteboard and I let them know I'm going to write all these things that you're telling me down here because they're important to me. However, it's also important for me to understand one thing at a time. So we'll write everything down and then we'll start kind of going through them one by one. That way the person knows that I care. If you don't have a whiteboard, no big deal. Write it down on a piece of paper. I also, in the spirit of making helping people feel safe, I let them know that if I write something down, you are totally welcome to read anything I write. And that is super important for a lot of clients because they think that we're writing down judgments about them or something. No, I, I'm taking notes so I remember everything you're saying because it's important to me. Summarizing is also important. Periodically stop people and this kind of goes along with clarifying, but periodically stop people and go, okay, this is what I'm hearing right now. You can also pull in stuff from prior sessions. We've been seeing each other for a month now. And when you initially came in, these were your presenting issues and what you said you wanted to work on. And we've done this, that and the other thing. And it seems like this is what I'm seeing now. Do you have something to add to that? Am I on point? And again, you're clarifying, but you're also bringing stuff together. Whether it's all the stuff that you've talked about in a session or summarizing what the last 30 days of treatment have been like or have worked through. Summarizing can be really helpful because gives that overview for the client so they can look up and go, well, yeah, actually I have come a long way, haven't I? When you're questioning people and we need to question sometimes try to keep it open ended. When at all possible. What are your thoughts on. Blah. What are your thoughts on about whether or not you have depression? What symptoms do you have that make you think that you've got depression or that you have an addiction? Those open ended questions allow them to answer something besides yes or no. Avoid why questions and confrontational questions. Now sometimes the word why is going to slip out and that's okay. It's not going to be harmful. You just don't want to hammer people with a litany of wise so they feel they're being Interrogated. Why did you do this? Why didn't you do that? Why? Why? Why? Okay, so what can you do instead? Instead of saying why are you doing this behavior? Say something like, I wonder how this behavior developed? Or what do you think is maintaining your addiction right now? What do you think is causing you to continue to want to use? Here's another one. Instead of why do you use. Tell me about the benefits to this behavior. Most people have never been asked about the benefits to the behavior. And basic behavior modification tells us that people choose the most rewarding option at any point in time. So there are benefits to their behavior. We just don't know what they are necessarily. And when you open that door and you say, tell me why this is working for you in some way, what are the benefits to this behavior? It makes the pain stop. Okay, tell me about that pain, Start talking about that, and then you can start figuring out alternate ways to meet that need. But until you identify the function of the dysfunctional behavior, you can't figure out what to replace it with. Ask the person and another question instead of why are you here? What do you hope to get out of today? Or what do you hope that treatment can do for you? Very different, but it doesn't feel nearly as interrogating. You can also use alternate perspective questions. If they get stuck or they are feeling they're kind of beating themselves up, you may ask them, if I asked your mother or your spouse or your best friend, pick one of them about this problem, what would they say? Or if I ask them about your progress over the past 30 days, what do you think that they would say? If I asked them why you're a good person, what would they say? The other option, or another option is if they start feeling like they are a bad person or it's hopeless, that they're going to get better or something. Ask them, if your friend had this problem, would you think less of them? Would you tell them it was hopeless and just to give up? Would you? What would you tell them if they were in your shoes right now, what kind of advice would you give them? And helping people get outside of their own head can sometimes help them find answers. Non verbals can also give you a lot of information just on their own, right? Pay attention to people's rate and volume of speech. If they're talking very slowly and very quietly, it could mean they're depressed, it could mean they feel intimidated, it could just be the way they talk. If they are speaking very rapidly and loudly, they may be in a manic episode, they may be angry or again, they. That may just be the way they talk. Pay attention to it and if it changes between sessions or even within sessions, you know that's something that is communicating a change in demeanor to you. Model appropriate rate and volume of speech. If a client is becoming agitated and starting to get loud, you don't want to tell them to tone it down because that's invalidating, but you don't also don't want to match their level of loudness because then they're just going to get louder and you'll get louder and it will escalate. So monitor and manage your own rate and volume of speech being as consistent as possible. Pay attention to people's posture. If they are face facing you and making good eye contact, that's great. That means they feel comfortable. If they have their arms crossed and they're kind of trying to shrink away, that communicates that they don't feel very comfortable. If they start talking about something and clenching their fists, then that may indicate that they're starting to get angry about something. Nonverbals communicate a lot, even when people's verbals may not change that much. Also pay attention to their facial expressions. That gives you a lot of information. Do remember that eye contact differs between cultures. So if somebody is not making direct eye contact with you, one of the things you need to think about is whether that is culturally appropriate for that person. American culture tends to be very eye contact dominant, if you will. But many other cultures believe that extended direct eye contact is is rude. So figuring that out if you have questions again, I know radical idea here. Ask the client. I notice that you're not making a lot of eye contact. I'm wondering if my making so much direct eye contact with you is making you uncomfortable. Think about what non verbals you can use to help people feel safe and respected and what non verbals of theirs tell you that they don't feel safe and respected. Other nonverbals that may help you meet the person where they are. Pay attention to the dress and presentation. I had clients, especially when I worked in the adolescent boys unit. They would communicate volumes by the way they presented themselves. When things were going well, they were bathing, they were combing their hair, they were doing all that stuff and it was wonderful. When they were feeling disheveled, out of sorts, confused, their presentation would be reflective of that. They would looked a lot, look a lot more disheveled. And I had one of my supervisees say one time to one of the clients. Your outside presentation tells me how you feel on the inside. It is a representation of how you feel on the inside. And that's always stuck with me. Their dress and presentation may communicate their state of mind. If they are dressed in all black from head to toe, if they could just be that that's how they felt dressing that day. But we do want to pay attention. If they are dressed in in particular ways that, you know, maybe they're wearing a T shirt that is particularly aggressive. You know, that is probably. They probably chose the T shirt for a reason. So think about it. Dress and presentation may also communicate cultural values and body image. How much are they showing and ver versus how much are they covering up? And it may communicate self concept. People who don't feel good about themselves often don't take care of themselves and they don't feel like they deserve to be taken care of. So if they're presenting in a slightly disheveled way, it could mean that they don't feel very good about themselves. It also could mean that they're completely overwhelmed and they have no energy and they're depressed and you're lucky that they actually made it to session. And that would look sort of like if they showed up and they were wearing yesterday's clothes that they slept in and it tells you things. Look for bodily signs of drug use, physical abuse, and again, poor activities of daily living. Are they showering? Are there, are they combing their hair? Are they brushing their teeth? Obviously they're probably not going to have food in their teeth, but if you can smell their breath from across the room, might be a clue. Skills for building the helping relationship Remember that both parties contribute to the relationship. If you're conducting the relationship and doing everything that's not helpful, you are at best establishing a dependency because you're doing it for them. You want to elicit from them, help them learn how to goal set, how to problem solve, how to apply these techniques. Effective communication from both parties is essential. You want to demonstrate credibility and dependability. I say what I mean and I mean what I say. And you can depend on me to show up for our appointments. You can depend on me to keep my word. Be respectful and responsive to their needs. Encourage expression of feelings. Not everybody likes the F word and that's okay. However, it's important for people to express their reactions, their sense of what's going on. And you may listen for words that they use if they don't like the word feeling. How do they describe things if they're not saying, you know, I felt completely devastated, maybe they say, it felt like I got kicked in the gut. Okay, Communicates about the same thing, but it doesn't use that scary feeling word. And that also may be a cultural thing that you need to be respectful of. Don't force talking about feelings if that makes somebody uncomfortable. Validate and recognize, but don't encourage nurturing negative feelings or behaviors. If somebody is enraged, validate it, recognize it. But we don't want them to hold it and carry it around with them for the next week. They've got this feeling, we recognize it. Let's talk about it. They're feeling enraged. That means they felt really threatened about by somebody. Let's talk about what you can do to address that feeling. Feelings are meant to spur you to behavior. Spirit feelings are meant to spur you to action, not to just sit there and stew in them. Same thing for behaviors. If somebody engages in unhelpful behaviors, whether it's self injury or addiction or sleeping all day, all right, we want to validate that. That behavior serving a purpose and, and recognize that it's communicating something and then talk about what is it communicating and what might you be able to do differently. Developing rapport is an essential process that takes place over the first couple of sessions. Developing rapport is an essential process that takes place over the first couple of sessions. Maintaining rapport is equally as important. Consider prior clients, relationships in which you felt like you had rapport. Think about times you did. Think about times where you had a relationship with the client where you just really could tell you didn't have any rapport. What was different, how did it feel different, how did you behave differently toward them, and how did they behave differently toward you? And now that you have some more tools, what might have caused that lack of rapport and what can you do differently the next time in order to address it? If you feel like rapport is breaking down.