Rapport and professional boundaries in therapeutic relationships

Rapport and Professional Boundaries

The work of Overholser and Fine (1996) states that: "Professional competence plays a prominent role in the guidelines established by all disciplines involved in psychotherapy, whether psychology, psychiatry, counseling, or social work." Related as well is that: "The Ethical Principles of Psychologists state that psychologists must 'recognize the boundaries of their competence and the limitations of their techniques'." (Overholser and Fine, 1996) Competence is not able to be assessed by any one given method because competence: "is a multidimensional construct." (Overholser and Fine, 1996) Professional competence has been defined a: "the provision of quality services through the application of professional knowledge, skills, and abilities." (Overholser and Fine, 1996)

The work of Norman (9185) proposed five categories of professional capabilities critical to competence which are those of:

Knowledge and understanding;

Clinical skills;

3) Technical skills;

4) Problem-solving and clinical judgment; and 5) Personal attributes.

I. Overview

Clinician Skills Identified

It is critically important that the counselor have the necessary clinical skills in order to assess and develop levels of rapport with the client that are of an adequate nature. (Anastasi, 1988) the clinician must be self-aware due to the "subtle ways that their own personalities, needs, and concerns can influence both the administration of tests and their interpretations." (Schafer, 1954; as cited in Overholser and Fine, 1996) the clinician must be able to adequately assess their clients as this is "a prerequisite for effective treatment because many problems cannot be appropriately treated until properly diagnosed." (Sheldon-Wildgen, 1982; as cited in Overholser and Fine, 1996)

Necessary qualities considered key in positive outcomes of therapy are: "adequate levels of empathy, warmth, and genuineness." (Egan, 1986; Ivey & Authier, 1978; Rogers, 1961; and Woodward and Gerrard, 1985; as cited in Overholser and Fine, 1996) These qualities, according to Woodwad and Gerrard (1985)."..promote understanding, trust and compliance in the clinical setting." (Overholser and Fine, 1996)

Other skills that have been cited include:

1) Composure;

2) Sensitivity;

3) the ability to communicate with a variety of clients; and 4) the ability to maintain an appropriate professional relationship with clients." (Overholser and Fine, 1996)

Three Identified Areas that are Source of Incompetence

Three areas are identified as the source of incompetence which are those of:

Informed consent - Informed consent is necessary prior to assessment or treatment

Advice-giving overused - This may promote short-lived behavioral changes and may cause noncompliant behavior from clients. This may also "render clients dependent on their therapists for additional direction and guidance." (Overholser and Fine, 1996)

Therapist self-disclosure excessive - when levels of disclosure are appropriate then a sense of genuineness is added in the clinical setting but excess self-disclosure on the part of the therapist may cause confusion for the client in that the line between the roles of friend and professional become blurred.

II. Importance of Rapport to Counseling Relationship

The importance of developing rapport with the client cannot be overstressed. Rapport will serve to effectuate communication between the clinician and the client. The Australian Psychology Association states that there are different mindsets that vary among clients therefore in the area of "interpersonal communication in therapy, being flexible and responsive is one of the most beneficial skills a counselor can have. Different mindsets and emotional states require a particular approach; and the counselor's ability to adjust to a client's needs is likely to dictate the success of that relationship." (Tips and Strategies to Build Rapport with Clients, nd)

Five Generic Profiles of Clients: Specific Strategies for Rapport Development

There have been five generic profiles of clients developed along with specific strategies to assist the counselor in gaining rapport with the client. Those five profiles are as follows:

Profile One - the Emotionally Unstable Client

The client who is not emotionally stable has greatly difficulty in self-expression. This client will generally require a client-centric approach. This approach is one that works to ensure that the client understands that they are in a safe environment and one that is friendly as well. Counseling strategies include the use of self-disclosure (creation of an emotional link), creation of goals and accountability for providing encouragement to client for action and for providing clear and positive communication. (Tips and Strategies to Build Rapport with Clients, nd)

Profile Two - an involuntary or skeptical client

This is the client who has been forced to attend counseling and may prove difficult to work with in the early stages of counseling. This client is skeptical and has not acknowledged any need for change. The counselor must gain the client's respect and upon that basis establish trust with the client. Solution-focused strategies are considered effective and the counselor should outline the counseling process, identify what the counselor's role is, and outline the rights and duties belonging to the client and finally the counselor should state the outcomes expected from counseling therapy.(Tips and Strategies to Build Rapport with Clients, nd)

Profile Three - the Child

This client is either a child of a young age or an adolescent. Trust may be established through the use of humor. Games encourage engagement and a collaborative approach and the counselor may use self-disclosure or role-playing to encourage communication. (Tips and Strategies to Build Rapport with Clients, nd)

Profile Four - the Uncommitted Client

This client is not committed and has attended counseling due to some agenda (example husband asked by wife to attend counseling) Framing and re-framing are strategies for use with this client and are good strategies in "remodeling the way the client perceives the counseling relationship" (Tips and Strategies to Build Rapport with Clients, nd) Creation of goals and structuring are also used in motivating the client to progress through the stages required for change.

Profile Five - the Demanding Client

This client generally holds the belief that the counselor will give them answers to their problems and generally holds expectations that are unrealistic in regards to the counselor and the counseling relationship. Strategies include:

1) Encouraging accountability;

2) Managing expectations; and 3) Establishing well-planned goals. (Tips and Strategies to Build Rapport with Clients, nd)

The client should be "encouraged to realize that change can only occur from within." (Tips and Strategies to Build Rapport with Clients, nd) Other strategies include the use of role-playing, narrative therapy skills, and a solution-fused approach for providing the client with empowerment and encouragement. (Tips and Strategies to Build Rapport with Clients, nd)

The work of James Delrojo entitled: "Six Tips for Building and Maintaining Rapport" states:

Rapport building is the art of helping another person minimize their perceived difference between themselves and yourself. Rapport happens at the subconscious level..." however, there are methods and strategies that can be used to assist the process." (Delrojo, 2004)

Six Strategies for Building Rapport

Six strategies for building rapport include the following:

1) Rapport starts at the beginning;

2) Give appreciation and importance to others;

3) Remember the skill of asking questions;

4) Use Active Listening;

5) Keep the ego under control;

6) Friendliness is key. (Delrojo, 2004)

III. Importance of Professional Boundaries to Counseling Relationship

The work of Gary R. Schoener entitled: "Assessment & Design of Rehabilitation for the Professional Who Has Violated Boundaries" states that: The importance of professional boundaries in healthcare goes back to some of the earliest writings in the Corpus Hippocratus, a body of medical writings housed in the Library of Alexandria in Egypt." (Schoener, 2004)

Common Reasons for Boundary Problems

The common reasons identified for boundary problems are stated to be those of:

1) Personality styles or psychiatric disorders in which normal boundaries are not recognized or respected;

2) Health professional stress/burnout; (3) cultural misunderstandings. (Barbour, 2007)

Examples of Boundary-blurring

Stated as warming signs and examples of potential blurring of boundaries include:

1) Gift giving from/to patient/family;

2) Patients having or wanting access to provider's home phone number, or other personal information;

3) Patient/family requests that the provider participate in prayer;

4) Patients having or wanting access to provider's home phone number or other personal information;

5) Patient/family expectations that the provider will care or socialize outside of clinical care settings. (Barbour, 2007)

Self-Reflection on Boundaries

It is important that the counselor ask themselves the following questions relating to boundaries:

1) Am I treating this patient or family differently than I do my other patients;

2) What emotions of my own does this family/patient trigger and are the emotions impacting my clinical decision-making?

3) Are my actions truly therapeutic for the patient, or am I acting in a manner to meet my personal needs?

4) Would I be comfortable if this gift/action was known to the public or colleagues?

5) Could this boundary issue represent a sign that I am experiencing professional burnout? (Barbour, 2007)

It is critically important that the counselor set clear expectations as to the role that they fill, the availability as related to that role, and the best mode of communication methods within the boundaries of that role. When uncertain the counselor should utilize colleague's advice concerning their or their patient's or the patient's and patient family's behaviors related to professional boundaries. The counselor should address issues at the time they occur with the patient and:

acknowledge importance of feelings, emphasize the provider-patient relationship and the importance of maintaining objectivity"; and finally "emphasize that the rejection of a requesting behavior does not imply a lack of caring." (Barbour, 2007)

If the boundary issues affect the ability of the counseling in providing objective and compassion care, the counselor should seek professional counseling for self and possibly for the patient and their family. (Barbour, 2007)

The work of Michael Liimatta entitled: "Issues of Personal Boundaries in Counseling: Part I" states that many times the phrase 'professional distance' is taken by people to mean cold and uncaring but in reality 'professional distance' is quite opposite of uncaring and is actually a strategy geared toward protecting the client from the counselors loss of objectivity." (Liimatta, 2001)

IV. Maintaining the Delicate Balance between Rapport and Professional Boundaries delicate balance must be maintained between rapport and professional boundaries so that the impact of the effectiveness of counseling is not negatively affected. Professional Boundary standards are of the nature of:

1) Legal;

2) Organizational;

3) Professional;

4) Ethical;

5) Emotional/Psychological; and 6) Personal Integrity.

Self-disclosure is a strategy utilized by counselors in developing rapport with their patients however, "Little research has been conducted on the effects of self-disclosure on the attitudes of patients and therapists." (Reexamination of Self-Disclosure, 2007)

Self-Disclosure: Attitudes among Patients

The following facts were stated in the findings of a 1974 study on therapist self-disclosure and patient attitudes:

There was no relationship found between the willingness of the therapist and the patient to self-disclose;

The expectations of the patient concerning the appropriateness of the self-disclosure of the therapist were influenced their actions in the event of self-disclosure;

Patients who expected self-disclosure from their therapists revealed more information to the therapist who self-disclosed less;

Patients who did not expect therapist disclosure revealed less information to "highly disclosing therapists." (Reexamination of Therapist Self-Disclosure, 2001; paraphrased)

Several types of therapy present self-disclosure opportunities and as well, self-disclosure may "contribute to the effectiveness of peer models..." (Reexamination of Therapist Self-Disclosure, 2001) Cognitive behavioral therapy and social skills training provides the opportunity for use self-disclosure strategies to "model coping strategies and problem-solving techniques." (Reexamination of Therapist Self-Disclosure, 2001)

In psychopharmacologic treatments, self-disclosure has been found to:

1) Increase rapport;

2) Enhance the therapeutic alliance; and 3) Increase medication compliance. (Reexamination of Therapist Self-Disclosure, 2001)

This report ends with the warning that: "Clinicians should recognize the benefits of self-disclosure as well as its dangers." (Reexamination of Therapist Self-Disclosure, 2001)

V. Respectful Persistence

The work entitled: "The Art and Science of Respectful Persistence" states that respectful persistence is:

subtle skill" which "strikes a delicate balance between diligently pursuing a prospect and always maintaining a high level of respect for the boundaries and wishes of the prospect." (Expert Business Development, 2007)

An important part of the training of respectful persistence is to "use each contact with the prospect as a way to underscore how important, satisfying and appropriate a relationship between our client and the prospect would be." (Expert Business Development, 2007) the key to achievement of this balance is "to be able to quickly engage the prospect on an emotional level and build rapport and trust."

VI. Current Research on Strategies and Interventions for Maintaining Rapport and Boundaries Simultaneously

The work of Nancy a. Bridges entitled: "The Vulnerable Therapist: Practicing Psychotherapy in an Age of Anxiety" "explores therapist and client vulnerability in a professional context that is increasingly (and unethically) rule-based." (1998) Bridges holds that "ethics rules are increasingly limiting therapeutic possibilities for clinicians and clients." (Bridges, 1998) Bridges writes of the "crisis of meaning in the mental health professions" and the inherent limitations that exist in rule-based ethics." (Bridges, 1998) in other words, questions remain in this area and in order that the professional counselor not be, found lacking in this area the professional counselor will be appropriately education and have proper training in the competence area of their practice.