Photo credit: Pixabay/LisaLove2Dance
Trust
by Kate Andres, LCSW
When we meet a client or patient we are working with for the first time, we often subconsciously make judgments or assumptions. Admitting this is an important place to start.
The decisions our clients make often feel perplexing, because they complicate a healthier lifestyle trajectory. Why can’t they just make decisions that will promote positive growth versus potentially negative outcomes?
Let’s consider the actualizing tendency theory. This cornerstone of the person-centered approach is the idea of human potentiality (Rogers, 1961, 1963). David Murphy, Maria Duggan, and Stephen Joseph (2013) clarify that the term actualizing tendency implies the tendency for people to proactively grow, develop, and move toward autonomous and socially integrated functioning when the social-environmental conditions are optimal. However, when the social environment is not optimal, the tendency toward growth is thwarted, resulting in development that is distorted in ways that lead the person in a negative, socially destructive direction (p. 708). These are typically the circumstances in which we find our clients, and it is where our curiosity about them can help build trust. I highlight this as a way to bring about more understanding, increased empathy, and decreased frustration for providers.
When we can be more grounded in the stage of change our client is in, we exude more patience and can be attuned to their present struggle. Building rapport in this way keeps the lines of communication more open. When our clients are ready to move to a different stage of change—potentially a more positive one—we can celebrate with them and feel less frustration. This aligns with one of the first social work tenets I learned early in my education: “Meet clients where they are.”
The stages of change model is often associated with substance use disorders, but it also is a useful tool to address any type of major change in someone’s life. In the revolutionary book Changing for Good, James Prochaska, John Norcross, and Carlo DiClemente (1994) outline the six stages of change:
- precontemplation (resisting change),
- contemplation (change is on the horizon),
- preparation (getting ready),
- action (time to move),
- maintenance (staying there), and
- termination (exiting the cycle of change).
They expand on this list by saying that a key to successful change for a person is knowing what stage they are in for the problem at hand (p. 39).
I would argue that it is equally important for the clinician to identify what stage of change your client is in as a way to better align with them. This creates an environment with less friction, allows for more curiosity on both sides, and invites a safer space for transparency. When we are honest about where our client is, we can truly be present. This reduces the sense of urgency to “fix them,” ultimately creating a relationship that feels free of judgment.
“Soft skills” are some of the most powerful tools you can have in your clinical toolbox. These are defined as “personal attributes that enable someone to interact effectively and harmoniously with other people” (Oxford Languages, n.d.). John DiJulius (2019) lists these attributes as authenticity, curiosity, listening, empathy, and appreciation for people. These often get taken for granted, and as a result, their importance in the process of rapport building is not emphasized.
Working with teen parents and pregnant teens helped me quickly learn the value of exuding an authentic energy. This had to be established within seconds of my presence in their exam room. DiJulius (2019) states that people have great “BS detectors,” so our interest in others and our desire to make a connection must be authentic. This can be done in multiple ways, but I found that simply maintaining good eye contact, keeping an open body posture, utilizing humor when appropriate, and remembering important facts about the patient are key. When I entered an exam room, I went straight to the patient to shake their hand and smile, and I used an open posture to provide reassurance that I could be trusted. I then provided simple, factual information about my role, the ways I could support them, and how our relationship would ultimately be a collaborative partnership.
Murphy, Duggan, and Joseph (2013) write that with a person-centered approach, the therapeutic relationship is based on principles and values such as unconditional positive regard, mutuality, and dialogue. The therapist and the client have the potential to experience each other as full human beings. The client is considered the expert and is free to determine their chosen path and the outcomes of the encounter (p. 705). Motivational interviewing opens this concept up even wider, highlighting that people already have within them much of what is needed and that the therapist’s task is to evoke it, to call it forth. The implicit message is: “You have what you need, and together we will find it” (Miller & Rollnick, 2013, p. 21). Creating this type of dynamic early on establishes a safe place for the person to process and take steps toward positive change. In this approach, there is no timeline, which can be hard given the reality of systematic constraints therapists face.
I will leave you with two skills I have found the most useful and the easiest to employ: humor and curiosity. Although we might not always see these traits in ourselves, they are instantly disarming. However, note that using humor in a clinical setting is a delicate process, and the social worker needs to be aware of when it is appropriate. Paul Osincup summarizes this so well by saying the key is to listen and follow a patient’s lead. If they’re using humor with you, then it probably makes them more comfortable (2020). And curiosity can complement humor. Being an “anthropologist” about your clients and their lives can make a big difference, especially if you have more time with them. People are generally surprising, and no one group or individual is exactly the same as another. If possible, don’t rush to get all the details of their history. Reflect back between visits on topics or tones they struck that you want to learn more about. With my teen clients, I used my electronic charting system to write virtual “post-it” notes. This is where I recorded details I was curious to learn more about with my patients. If they were slower to build rapport, this created an easier dialogue and told them in an indirect way that I cared to know more.
As you navigate different clinical settings and their internal structures, I urge you to remember the most simplistic of clinical methodologies: social connectedness. Helping others to feel connected, heard, and seen is at the core of why we became social workers. As clinicians, we ultimately don’t get to decide how long we work with an individual or family. Most can terminate services at any time or leave against medical advice. As you review this information, recognize where you naturally exhibit some of these skills and where you can stretch some new muscles. In a sense, I am challenging the profession to go “back to the basics”' in an effort to create spaces where rapport grows organically.
References
DiJulius, J. (2019, November 19). Soft skills: How to master relationship building. The Enterprisers Project. https://enterprisersproject.com/article/2019/11/soft-skills-how-master-relationship-building
Merriam-Webster. (n.d.) Rapport. In Merriam-Webster.com dictionary. https://www.merriam-webster.com/dictionary/rapport.
Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed). Guilford Press.
Murphy, D., Duggan M., & Joseph S. (2013, June). Relationship-based social work and its compatibility with the person-centered approach: Principled versus instrumental perspectives. British Journal of Social Work, 43(4), 703-719. https://doi.org/10.1093/bjsw/bcs003
Osincup, P. (2020, July). How to use humor in clinical settings. AMA Journal of Ethics, 22(7), 588-595. doi:10.1001/amajethics.2020.588
Oxford Languages. (n.d.). Soft skills. Oxford Languages (Google online dictionary).
Prochaska, J. O., Norcross, J. C., & DiClemente, C. C. (1994). Changing for good: A revolutionary six-stage program for 9vercoming bad habits and moving your life positively forward. HarperCollins.
Rogers, C. R. (1961). On becoming a person: A therapist’s view of psychotherapy. Boston Houghton Mifflin.
Rogers C. R. (1963). The actualizing tendency in relation to “motives” and to consciousness. In Jones M. (Ed.), Nebraska symposium on motivation (pp. 1–24). Lincoln: University of Nebraska Press.
Kate Andres, LCSW, is a licensed clinical social worker in Colorado. Her work spans a variety of clinical settings, including schools, outpatient community mental health, hospitals, and shelters. Working with vulnerable populations has provided her with unique insights on forming alliances to effectively promote change.