Mussa Emmanuel (MD).

RAPPORT: It can also be defined as a close and harmonious relationship in which there is common understanding.

TRUST: a firm/strong belief in someone or something or acceptance of the truth of a statement without evidence or investigations.

Therapeutic relationship, also called the helping alliance, the therapeutic alliance, and the working alliance refers to the relationship between a health professional and a patient or client.

It is the means by which a professional hopes to engage and stimulate change in a patient.

Studies have found that the extra trust alone that comes with a strong therapeutic relationship has been shown to significantly improve the therapeutic outcomes of treatments.

In other words empathy means ability to understand and share the feelings of another

Rapport: It is defined as a close and harmonious relationship in which there is common understanding.

The client needs to be able to talk openly and honestly, and the therapist/ clinician needs to be able to listen without judgment.

Trust: a firm/strong belief in someone or something or acceptance of the truth of a statement without evidence or investigations.

The client needs to trust the therapist/clinician, and the therapist/ clinician needs to trust the client, although building trust may take time.

For a therapeutic relationship to be established and maintained throughout history taking, a clinician needs to use the techniques that form the basic tools for interview. These techniques include:

Genuineness: The therapist/clinician needs to be a ‘real’ human being, not an all knowing, all powerful, rigid, and controlling figure.

Unconditional positive regard: Involves experiencing a warm acceptance of each aspect of the client’s experience as being a part of the client. There are no conditions put on accepting the client as who they are. The clinician needs to care for the client as who they are as a unique individual.

Empathy: A basic therapeutic aspect that has been taught to clinicians over and over. It is essential to have the ability to enter the client’s ‘private world’ and understand their thoughts and feelings without judging them.

Collaboration: Shared agreement on goals in therapy. The therapist/ clinician and the client must work as a team to develop mutual understanding, and to set and follow through on goals. In therapy clinicians must develop goals that the client would like to work on rather than dictate or impose goals on the client. When clinicians have their own agenda and do not cooperate with the client, this can cause resistance and a separation in the helping relationship.

Humour: Humour is an excellent coping skill and is extremely healthy to the mind, body, and spirit. Try laughing with your clients. It will have a profound effect on the relationship as well as in your own personal life. It also allows them to see the therapist as a down to earth human being with a sense of humour.

This is the process of closely attending to what the patient is communicating, being aware of the patient’s emotional state and using verbal and non verbal skills to encourage the speaker to continue and expand.

This allows a clinician to understand precisely at multiple levels of the patient’s experience.

This is a way of a clinician asking for more information from the patient without interfering with the flow of patient’s history.

The goal is to facilitate the patient’s fullest communication and encourage the patient to disclose while minimizing the risk for distorting the ideas or missing the significant details.

When you ask a patient questions: be sure to ask in a way that will make a patient continue to speak and provide information:

Move from open ended to focused questions. For example: ‘Tell me about your chest pain (pause). What else’? (pause)

Ask questions that elicit a graded response. For example: ‘How many steps can you climb before you get short of breath’? Is better than ‘Do you get short of breath climbing stairs’?

Do not ask a series of questions. Ask one at a time, pause before you go to the next question

When you ask a patient questions: be sure to ask in a way that will make a patient continue to speak and provide information:

Offer multiple choices for answers, when the patient seems quite unable to describe their symptoms. To minimize bias offer multiple-choice answers

Clarifying what the patient means. When the patient uses words that are ambiguous or have unclear associations request for clarification so that you all have the same understanding. For example: ‘You said you were behaving just like your mother. What did you mean’?

When you ask a patient questions: be sure to ask in a way that will make a patient continue to speak and provide information:

Encouraging with continuers; without specifying content you can use posture, gesture, or words to encourage the patient to say more. Example: leaning forward, using phrases like ‘Mm-hmm’, or ‘Go on’, or I am listening.

Echoing. This is a simple repetition of the patient’s last words, encourages the patient to express both factual details and feelings, for example; Patient: ‘The pain got worse and began to spread’ (pause); Response: ‘Spread’? (pause) Patient: ‘Yes it went to my shoulder and down to my left arm, to my fingers. It was so bad that I thought I was going to die’. Response: ‘Going to die’?

This is communication that does not involve speech, it occurs continuously and provides important clues for feelings and emotions.

Non verbal communication will assist the clinician to effectively read the patient and send his own messages.

You need to pay close attention to eye contact, facial expressions, posture, head position and movements such as shaking or nodding, interpersonal distance and placement of the arms or legs – crossed, natural, or open.

Conveying empathy greatly strengthens patient rapport.

As patients talk with you, they may express – with or without words – feelings they may or may not have consciously acknowledged. These feelings are crucial to understanding their illnesses and to establishing a trusting relationship.

To provide empathy you must first identify the patient’s feelings.

Once you have identified the feelings, respond with understanding and acceptance. Responses may be as simple as ‘I understand’, or ‘That sounds upsetting’, or ‘You seem sad’.

Empathy may also be non verbal, for example offering a tissue to a crying patient or gently placing your hand on the patient’s arm.

This is making a patient feel affirmed or acknowledged of the legitimacy of their emotional experience.

For example, a patient who has been in a car accident but has no physical injury may still be experiencing significant stress.

Reassuring such patients by saying ‘I know it must be very scary, but you will be ok’ helps the patient feel that their emotions are legitimate and understandable.

When you are talking to a patient who is upset or anxious, it is tempting to try to reassure them.

Keep in mind that premature reassurance may indicate to patient that a clinician is uncomfortable with the anxiety and block further disclosure, or may bring about wrong reassurances to the patient.

The first step to effective reassurance is simply identifying and acknowledging the patients feelings. This will promote the feeling of connection.

The actual reassurance should come much later after you have completed the interview, the physical examination and perhaps some laboratory studies, when you are genuinely sure of the patient’s condition.

When building a relationship with a patient, make explicit of your desire to work with them in an on going way.

This reassures them that regardless of what happens with their disease, you are committed to a continuing partnership.

This is giving a summary of the patient’s story during the course of the interview.

It serves to communicate to the patient that you have been listening carefully.

It also identifies what you know and what you don’t know

Example: ‘Now, let me make sure that I have the full story. You said you have had a cough for three days, that it’s especially bad at night, and that you have started to bring up yellow phlegm. You have not had fever or felt short of breath but do feel congested, with difficulty breathing through your nose’. Follow with a pause, or by asking ‘Anything else’?

This technique also helps you to organize your clinical reasoning and convey your thinking to the patient.

This is moving from one part of the history to the other. For example, you have been interviewing the patient about the history of presenting illness, and now you ask about the past medical history.

At this point you need to inform the patient about your plan and you can use phrases like, ‘Now I would like to ask some more questions about your past health’

The clinician patient relationship is inherently unequal.

Patients feel vulnerable due to a number of reasons including pain, worry about symptoms, being unfamiliar with the health care system and the process that a clinician takes for granted.

It is a clinician’s role to empower the patient to reach the self confidence and understanding of the recommendations.

For a clinician to be able to empower the patient, he can do the following:

Take into consideration of the patient’s perspective

Convey interest in the person

Follow the patient’s leads

Elicit and validate emotional content

Share information with the patient, especially at transition points during the visit.

Make your clinical reasoning transparent to the patient

Revel the limits of your knowledge

Boundaries of a therapeutic relationship are the limits that allow a safe connection between the clinician and the client that is always based on the client’s health needs.

Clinicians taking patients history are accountable and responsible to maintain the boundaries of professional relationships, to act as a client advocate and, when appropriate, intervene to prevent or stop boundary violations.

Strategies the clinician might consider using in maintaining therapeutic relationships during history taking include the following practices:

Understanding the limits of the therapeutic relationship

Adhering to the plan of care

Communicating the expectations for and limits of confidentiality

Being sensitive to the context in which the care is provided

Implementing reflective practice

Concluding the therapeutic relationship

A boundary violation occurs when a clinician places their own needs above the needs of the client.

Some of these behaviours may be seen as helpful to a client, however are considered unacceptable as they focus on or meeting the clinician’s personal needs and/or pose a risk to the therapeutic relationship.

Accepting gifts from clients

Entering a therapeutic relationship with family or friends

During history taking and physical examination a clinician should know that the following behaviours are unacceptable:

Abuse (physical, emotional, verbal, sexual or financial)

Initiating a social/personal relationship with a patient

Neglect

Acting as a representative for patients under powers of attorney or representation agreements

Prejudice – neither the client nor the therapist should ever use racist or sexist language or behaviour, or express any prejudice based on characteristics such as religion, background, sexuality, marital status or other personal characteristics.

What is a therapeutic relationship?

What are the boundaries of therapeutic relationships?

What are the behaviors which are unacceptable in a therapeutic relationship?

What are the four the techniques for skilled interviewing?

The therapeutic relationship refers to the relationship between a health professional and a patient by which the professional hopes to engage with, and effect change in, a patient.

Therapeutic relationships are cemented into seven important characteristics including: rapport, trust, genuineness, unconditional positive regard, empathy, collaboration and humour.

Effective history taking relies very much on the therapeutic relationship that is made between the clinician and the patient.

A clinician needs to consider that there are boundaries in a therapeutic relationship and they should not be violated during history taking.