Rapport can occur in any social situation. The type of rapport developed in therapeutic situations has its own special characteristics and serves as the building block upon which the relationship rests and it is one means by which a patient achieves therapeutic outcomes. Rapport involves the interpersonal influences arising between patient and clinician that can support the patient’s desire to be involved in therapy and to participate with the clinician in constructing a new vision of possibilities. Early in the relationship the patient communicates a need for help with pain, the clinician acknowledges the pain and offers help.

In this early stage of rapport development, shared recognition of the patient’s pain helps to establish the working relationship and serve as the foundation for planning and initiating interventions. A clinician’s ability to empathize, to understand in feeling terms every patient’s subjective experience, is important to the development of rapport. Empathy is particularly important in complex interpersonal behavioral problems in which the environment (family, friends, schools, caretakers) may wish to expel the patient, and the patient has therefore lost hope. For example, suicidal patients and adolescents involved in intense family conflicts can often be convinced to cooperate with an evaluation only when the clinician has shown accurate empathy early in meeting with the patient. When the clinician acknowledges the patient’s pain, the patient feels less alone and inevitably more hopeful. This rapport establishes a set of principles of – and expectations for – future interaction. More elaborate goals and responsibilities of the patient can be developed on this basic building block.

Professionals working with people whose illnesses are expressed through disturbances of thought, perception, emotion, and behavior are called upon to have special expertise in establishing the therapeutic relationship which, along with rapport, is heavily dependent on the ability to listen.

Therapeutic listening defies straightforward definition. However one defines the process it requires exquisite sensitivity to the storyteller and the ability to integrate a humanistic orientation with that of a diagnostician and problem-solver. The listener’s intent is to uncover what is wrong and at the same time find out who the patient is, employing tools of asking, looking, testing, and clarifying. Patients are active informers and partners in this process. Listening work takes time, concentration, imagination, a sense of humor, respect, and an attitude that places patients as the heroes of their own stories. Clinicians of all disciplines and theoretical persuasions must learn and use the skill of listening.

The therapeutic relationship is a collaborative social process based on reciprocal trust, respect and professional intimacy. This relationship is a mini-ecology within which the work of healing takes place. It requires the appropriate use and balance of knowledge, empathy, and power. In its generic form, it is characterized by the collaboration between expert clinicians and help-seekers to identify, understand and solve problems. The therapeutic relationship is the central medium through which all psychiatric care is provided.

Certain key elements must exist for a therapeutic relationship to develop. These elements include trust, mutual respect, caring, self-awareness and partnership.

2.4.1 Trust

As in all close relationships, the foundation of a therapeutic relationship is trust. People with mental health problems may be particularly reluctant to trust others because they are in emotional pain and may fear being misunderstood. Clinicians must earn patients’ trust through their caring presence and sensitive interactions. Some behaviors that foster the development of trust include predictability, consistency, and clear expectations.

Trust is also based on the knowledge that one is accepted without judgment. Mental health problems are often accompanied by shame about socially alienating symptoms (e.g., hallucinations, flashbacks, withdrawal) and an inability to manage relationships with others. Patients need to know that clinicians will not blame, fear, or look down on them. This means that clinicians must gain a level of comfort with psychiatric symptoms so that they can fully accept patients regardless of their level of functioning.

2.4.2 Mutual Respect

A therapeutic relationship is based on mutual respect. Although the stigma surrounding mental illness has decreased with greater awareness of the biologic and genetic factors that contribute to patients’ conditions and wider use of mental health services, patients and their families still encounter negative and condescending attitudes.

Families of people with mental illnesses often fear being criticized or blamed for causing their loved one’s problems. This fear may be rooted in the long history of psychological theories that attributed psychiatric disorders to childhood traumas and family dynamics. Mental illness places a great strain on families who cope daily with such problems as mood swings, unpredictable behavior, and continual dependence on others. In most cases families are doing the best they can to help their loved ones while also coping with their own, often stressful circumstances.

In a therapeutic relationship, respect must be both given and received. Clinicians will need to set limits when patients are disrespectful so that the boundaries of the relationship remain intact. A calm, non-defensive, and respectful demeanor will help to set the tone for professional interaction and reduce unproductive and potentially relationship-destroying emotional outbursts.

2.4.3 Caring

Creating a therapeutic relationship involves expending time and energy. Caring means having the energy and optimism to keep trying to help patients, even in the face of discouragement. Caring also involves showing empathy for patients by listening to their points of view and trying to understand their experiences. Rogers identified three major ingredients of effective helping relationships: empathy, genuineness, and unconditional positive regard.

Empathy