When discussing working with clients experiencing active psychosis, I once had a counseling student ask me, “Dr. Lott, what’s the point of trying to build a relationship with a client who isn’t even sure they are on the same planet as me? I mean, does it really matter at that point if I get to know them?” Taken aback, I responded, “If this client were your loved one, would you still have this question?” This exchange helped the student realize the importance of seeing clients from a place of compassion, no matter their symptoms, but it also made me wonder how often other students and counselors have pondered this same question.
In a traditional counseling session, building rapport is one of the most important tasks that the therapist will have. Rapport building helps the client feel welcomed, heard, seen and validated and helps improve the therapeutic process. In addition, research supports the notion that the counselor-client therapeutic alliance has a significant impact on treatment outcomes. Thus, regardless of the issues clients bring to session, the relationship bonding between the therapist and the client is essential.
But what about clients who are actively experiencing psychosis? Should therapists take the same time and effort to build a relationship with them? The straightforward answer is a resounding yes, but unfortunately, many clinicians do not always intentionally practice this.
Research studies indicate that counselors agree on the importance of rapport building with this population. So, if counselors know that this is important, then why do some struggle with this when it comes to working with individuals diagnosed with active psychosis? Nearly all the supervisees I have worked with have told me that they initially had a difficult time building rapport with clients experiencing psychosis. Because this process can be challenging and unique for clients with severe mental illnesses, I offer insights from my own experiences on why building rapport is important for this population and effective strategies on how to do it.
The need for rapport building
Throughout my research and work with the mental health community, I have noticed many articles implying that individuals living with severe mental illnesses are violent or dangerous and that caution should be taken when working with this group. Some articles talked about the importance of managing a hostile environment and being aware of exit doors and ways to call for help should things escalate. Although this is possible in some cases, hostility and danger have not been my experience when working with this population, and I have worked with some of the most severe forms of psychosis. In most cases, I have not felt threatened or on edge when working with this population. This sort of thinking is more prevalent due to the stigma associated with severe mental illness. I have found that people are often afraid of what they do not understand, and therefore those with severe mental illnesses are often ostracized, discriminated against and stereotyped.
During my 11 years working with clients experiencing severe mental illnesses, I have found that my rapport with clients supports them in treatment by helping them adhere to medication (when applicable and desired) and engage in services specifically designed to help reduce symptomatology. Clients who are experiencing active psychosis are likely to be skeptical of anyone outside of their world. Some symptoms, such as paranoia and severe anxiety, may have convinced them that others, especially mental health professionals, do not have their best interests in mind. Often, their reasons for suspicion and skepticism are warranted. Many clients with severe mental illnesses have had negative and often traumatic experiences with the counseling profession due to well-intentioned but poorly trained or unaware clinicians. Therefore, the odds are against us when it comes to building the therapeutic alliance.
Even though it is challenging, I’ve found that building a therapeutic alliance with this population is one of the most effective interventions counselors can implement. In addition, it can be a positive interaction that counters any potential negative mental health experiences clients have had in the past. It is safe to say that regardless of whether a client is experiencing active psychosis, having someone that they trust is always helpful when it comes to the treatment plan, emotional and psychological commitment, and their overall well-being. And for clients with severe mental illnesses, it is a necessity.
There are many benefits to creating a strong therapeutic alliance, but here are three main reasons why rapport building is important for clients with severe mental illnesses:
- Trust creates relationships and relationships can lead to progress. A client’s trust in their mental health professional provides an opportunity for the client to receive care. No matter how severe one’s psychosis may present, trust is important when it comes to adherence. If a client does not trust their team, they are less likely to engage in the services offered to them. Clients need to know that mental health professionals have their best interests in mind and that the goal of counseling is to help them find relief from the symptoms that may have caused them to seek or receive treatment. Building a trusting relationship with just one mental health professional can help clients de-escalate when they are in a state of crisis, assist with medication and therapy adherence, and encourage the client to be an active change agent when addressing collaborative treatment plan goals.
- A sense of connection and belonging can build community. Those with severe mental illnesses often feel alone and misunderstood, which can cause them to self-isolate. Research has shown that people diagnosed with severe mental illnesses tend to connect with others who have severe mental illnesses because they do not feel a sense of belonging with people who do not have similar diagnoses. According to Patrick Corrigan, the program director of the Honest, Open, Proud program (which aims to reduce the self-stigma associated with mental illness), one of the best ways to understand people with severe mental illnesses is by forming connections, having conversations and engaging in shared activities with them. Counselors can establish a healthy connection with this population by engaging in the client’s community as an observer, remaining curious by asking questions, dispelling biases and stereotypes, and working with the client in a benevolent and nonjudgmental way. When counselors approach clients from this perspective, clients are more willing to allow the counselor in, which helps foster an authentic relationship and a sense of community.
- A strong rapport positively affects treatment outcomes. In the first edition of his book The Basics of Psychotherapy: An Introduction to Theory and Practice, Bruce Wampold said the therapeutic alliance is one of the most important aspects of the counseling process and it often leads to favorable outcomes. This continues to be true today. Wampold stressed that the stronger the alliance early on, the better the outcome. The trust developed between the counselor and the client is a sacred and unique connection that happens within the counseling session, and it creates a safe place for the client to express their inner thoughts without judgment. For some clients, it may be the first time they have experienced a healthy relationship. Individuals with severe mental illnesses have most likely felt betrayed by the mental health system and are therefore reluctant to share how they truly feel. For example, a client once told me that he did not want to share how he felt because he feared he would be hospitalized or punished. After taking the time to reassure the client that I was there to listen and support him, he started to share his true emotions. Gaining the client’s trust could help uncover many other symptoms that get in the way of the client living their optimal life. Lessening of the severity of symptoms and connecting the client to the appropriate resources, in turn, can reduce their need for mental health services and address symptoms that may have led to hospitalization in the past. In other words, the bond formed between the counselor and client has the potential to decrease the cyclical impact of overutilized mental health services because clients are listened to and validated.
Strategies for building rapport
I think that depending on the environment, the culture of the clients you are working with and the clinician’s skill set, there are many ways to connect with clients with severe mental illnesses, including those experiencing psychosis. In my extensive work with this group, I have found that the following strategies work exceptionally well.
Get on the same page as your client. The counselor and the client should always work collaboratively toward the client’s stated goals. Frequent check-ins to make sure that the goal has not changed are important when it comes to assessing progress. When counselors make goals for the client as opposed to with the client, a therapeutic disruption occurs, resulting in the client not being an informed and active change agent toward their goals.
When working with psychosis, establishing a common goal may require the counselor to be more flexible and creative in their approach. For instance, I worked with a client who heard voices and her main goal was to stop her voices from disrupting her while she studied. Of course, I could not guarantee that she would achieve this goal, but what I could do was offer ways in which the client could learn to tolerate the voices so that she could still study. So we adjusted the therapeutic goal to focus on learning coping strategies to distract her from the voices.
Counselors have the responsibility to make sure that treatment is geared toward the client’s benefit, wellness and preferences. When this alliance is in place, treatment outcomes can improve.
Stop talking and listen. One of the most effective interventions for working with any client, especially those who are experiencing psychosis, is to listen to the message that the client is trying to convey. When working with psychosis, there is some truth in even the most delusional of statements. I once worked on a psychiatric unit and had a client who believed that the devil lived in his rectum. Most of the mental health providers that he had encountered before me dismissed this statement, often attributing it to his psychosis. When I did my assessment of him, I asked more questions about this “devil.” I asked what it looked like and why it might have chosen to live in his body. Although his response was tangential and disorganized, I learned that this “devil” was really the client’s way of telling us he had been sexually abused. This “devil” was a result of trauma. It represented one of the most detrimental moments in his childhood. Had others mental health professionals listened and been more patient, it is possible that his trauma could have been addressed much sooner.
Hold back your urge to assess and evaluate. Over the years, the agenda in the counseling profession has been clear: Diagnose and then move the client through the treatment process. So it has become second nature for clinicians to walk into a session, assess a client, assign a diagnosis for billing purposes and move on to the next client.
The problem is that clients can see right through this. They can tell when there is an agenda or when they are a part of this system. Clients come to the session to feel heard and validated. They do not want to be a part of the “mental health assembly line.” Clients who have had a long history of being a part of the mental health system often feel like just a number or another item to cross off a counselor’s checklist. This has decreased their trust in the mental health profession. In addition, it has made clients not want to disclose and tell their stories because they are in the room with yet another entity who will write it all down, not thoroughly address what was shared, and then move them through therapy without ever really addressing the core issues or providing resources for dealing with what they shared.
Clients are constantly asked to be vulnerable and do not always get what they need in return. Clients with severe mental illnesses have often experienced significant trauma in their attempts to address their mental health needs, so having a counselor who is curious, welcoming and nonjudgmental can create for a strong foundation for a therapeutic alliance. Diagnosing is necessary, but it does not have to come before a therapeutic relationship is built.
Do not argue with delusions; they are a symptom of something bigger. When working with clients who experience symptoms such as delusions or hallucinations, I have seen new and even seasoned counselors get into a power struggle with clients. This never ends well, and it greatly diminishes rapport. Counselors who enter a power struggle often focus on the wrong things in session. This is especially true with clients who present with psychosis. It is human nature to debunk something that seems untrue. When aware, it is even natural to debunk things that are irrational. But this is not ideal in the beginning stages of rapport building. When working to build rapport, telling a client that their delusions and perceptions are not real is like saying you do not want to hear what they have to say. It communicates that you are another person in their life who is not listening to them.
Instead, if counselors focus on the symptoms that are getting in the way of the client’s everyday goals, they could help the client make more progress. For instance, I once worked with a client who believed that people put snakes in her soup. Because of this, the client would not make or eat any soup. Instead of confronting the client and making a case that there were no snakes in her soup, I focused on the foods that she enjoyed eating. Last time I checked, you cannot starve from not having soup as a part of your diet, so I focused my attention on the symptoms that mattered in her day to day and did not spend energy debating about delusions that had no real bearing on her well-being. I have found that when we concentrate on helping clients focus on their personal goals and everyday functioning, some of the psychotic symptoms tend to take a back seat and are less of a disturbance.
In her master’s thesis, “Best practices of building therapeutic alliances with clients living with psychotic disorders” (published by St. Catherine University in 2017), Nicole Rominski expressed similar thoughts when she stressed the importance of focusing less on diagnostic criteria and challenging delusions and more on the distress that the symptoms cause because this is the more significant issue. Doing this does not mean the symptoms go away, but they are less likely to consume the client’s attention, which would be a positive outcome for many clients with psychosis.
Ask how you can assist and do what you can to help. Our main role is to assist, advocate and support the clients that we work with. If you work with clients who are actively experiencing psychosis, you may wonder what they would need to feel supported. That’s a great question, and the client is the person best suited to answer it. Asking a client how you can be of support to them or what you can do to help them can open the doors in two ways. First, the client understands that you want to listen to them and you are there to help them. Second, it helps build trust between you and the client, especially if it is the first time a mental health professional has directly asked them this question. Even if you cannot support them in the exact way they want, you can still listen, provide resources that address their needs and show the client that they matter.
Humanize the experience and share the client’s story with the treatment team. Once you have done the important work of taking time to listen, validate, empower and advocate for your client, share what you have learned with the interdisciplinary team. You have an insider’s view of what the client is experiencing. You have deciphered the hidden messages within the delusions and gotten to the core of the message that the client is trying to share. It is important to make sure that others who will be working with this client know this information as well.
This approach also benefits the client in three ways. First, sharing the client’s story humanizes them and allows their diagnosis to take a back seat to who they are as a person. In other words, we see the person first and not just their diagnosis. This does not mean that symptoms will be ignored and unaddressed; instead, understanding the client in context is crucial to effectively treat their symptoms. Second, sharing this information also helps family, friends, mental health providers and others know how to approach the client, which in turn can help the client feel safe. And it saves the client from having to repeat their story. Third, the treatment plan will be more individualized for the client now that their symptoms can be understood and addressed in context. In turn, health professionals can better understand and target the underlying causes of distress, thereby improving the client’s mental health and well-being.
There are many reasons why it is important to build a trusting bond with our clients. For those with severe mental illnesses, building rapport is the most important step when it comes to seeing positive change and progress. Stigma has exacerbated some of the most harmful myths associated with clients living with severe mental illnesses and has caused significant misunderstandings related to how to establish a rapport and working relationship with them.
I am thankful to the student who bravely asked about the point of trying to build a relationship with a client in active psychosis. Not only did it help me realize how common it is for people to contemplate this question, but it also motivated me to provide some clarity and understanding regarding this population and the challenging work that comes with it. I am grateful to the hundreds of clients I have worked with that have taught me how to remain curious, compassionate and solution focused to address their needs and wants from the counseling profession.
Tina C. Lott holds a doctorate in counselor education and supervision and is a licensed clinical professional counselor, certified alcohol and other drug counselor, national certified counselor, approved clinical supervisor and board-certified telemental health provider. She serves on the board of directors for the National Board for Certified Counselors’ Center for Credentialing & Education, and she is an academic program coordinator and core faculty member at Walden University. She has a YouTube channel specific to addressing stigma and all things mental health. In addition, she is an independently contracted therapist at PATH mental health, a mother of two fantastic kids and wife to her life partner. Contact her at firstname.lastname@example.org.
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Extremely Helpful Article.
Thank you so much.
I believe this approach with psychotic clients used to be called paradoxical therapy. Is that phrase no longer used?
Awesome, Dr. Lott!
This is so insightful. I supervise addiction counselors who are often confused and skeptical about working with psychosis in patients, especially given that we are a medication assisted treatment program. The concern is that patients in psychosis are not able to manage take home medication and/or that the patient has difficulty establishing and maintaining a stable dose of methadone or buprenorphine. We have a psychiatrist available, but he does not treat severe mental health disorders in our patients (conflict with accreditation). Therefore, coordination of care with mental health providers is optimal. However, we find that mental health providers are reticent to treat patients who are enrolled in medication assisted treatment.
On so many levels, the challenge of serving patients with psychosis has resulted in unsuccessful or premature discharges. Your article will help me to encourage my supervisees to find ways to engage our patients, advocate for them, and build that trusting relationship that is so necessary in supporting well-beling.