Therapeutic alliance - or how to build trust with your clients

I can spot a McGill trained doctor at 50 paces.

My brother-in-law was trained at McGill. So was the internist who diagnosed my Dad's cancer. And my friend's plastic surgeon wasn't McGill trained, but his father and uncle were, and it clearly rubbed off on him.

So what did they learn at McGill that enables them to be such extraordinary doctors? Therapeutic alliance.

As a lay person, I can't speak with any authority on this. I can only share what I've observed.

Take my brother-in-law. Despite practicing obstetrics - the most litigious medical specialty in the States - for the past 30 years, not one of his patients has ever sued him.

Wikipedia says therapeutic alliance

refers to the relationship between a health care professional and a patient. It is the means by which the professional hopes to engage with, and effect change in, a patient.

So what does this have to do with you? And why is it critical to helping your clients?

It has been found to predict treatment adherence (compliance) and concordance and outcome across a range of patient diagnoses and treatment settings.

Here's an example from my own recent past. When my son-in-law Dave was transferred from a trauma hospital to a local hospital after a catastrophic accident, he refused to let the nurses in the new hospital bandage his leg, and so my daughter, Emily, took over. He insisted that Emily was the only one who did the bandages properly, and student nurses were brought in to observe her in action.

Emily has no medical background. In fact, she's a 21-year-old sheet metal apprentice. So I asked how she was able to do this, and she said, "I listen to him. He knows what works, and that's what I do."

Indeed! And that's what's unique about all three McGill-trained doctors: When they're with their patients, they aren't taking notes or lecturing. They're sitting with their patients, giving them their undivided attention, and listening. As one doctor said to me, "Often you don't need a lot of expensive tests. If you really listen to your patients, they'll tell you everything you need to know."

Like Dave, I don't trust professionals who dismiss what I have to say and won't take the time to listen to me.

Therapeutic alliance is usually discussed in the context of health care and therapy. But whether you're a teacher, a nurse or a frontline worker, your success depends on being your clients' ally. And partnering with your clients doesn't mean "knowing what's best" or "knowing how to fix it." It means building a relationship of trust with your clients.

Instead of assuming you know what your clients need and jumping in with solutions that may or may not work, try this:

• Ask questions to find out what your clients really want.
• Listen to what they have to say in a way that respects and honours them.
• Provide them with the information they need, and make suggestions.
• Encourage them to use that information to create their own solutions.
• Trust that, in most cases, the solutions they come up with will be the best solutions for them.

For those of you who want more information, an article entitled Therapeutic Alliance, Focus, and Formulation: Thinking Beyond the Traditional Therapy Orientations by Robert-Jay Green offers great insights into the "flavour" of therapeutic alliance. I would also highly recommend Reality Therapy by William Glasser.

For one week, give up listening to respond, fix and solve, and instead listen to understand. And let me know what happens when you do!

Can we talk? - Putting an end to gossip

One of the most destructive workplace habits is gossip.

Nobody wants to be the subject of gossip - even when it's not malicious. But almost everyone participates. And gossip fosters an emotionally unsafe work environment because it usually involves blaming, complaining or criticizing.

There are hundreds of articles on why we gossip, but the focus of this article is how to stop it!

Gossip creates an unsafe work environment when -

• It's unsustantiated.
• It doesn't concern the gossiper and/or the listener.
• It calls the subject's credibility or reputation into question.

 Sai Baba provided an excellent checklist for monitoring our social chit-chat:

• Is it true?
• Is it necessary?
• Is it kind?
• Does it improve on the silence?

There are three things you can do to put an end to gossip:

• Don't start it.
• Don't pass it along.
• Don't listen to it.

Don't start it.
Even though you have control of what you say, you may find that giving up gossip is a hard habit to break. But you break the habit the same way you get to Carnegie Hall: practice, practice, practice!

Don't pass it along.
What do you do with the busybody who suspects you know what's really going on with Mary and is pressuring you to spill the beans? Here are a couple of my favourites. The second is a standard line that a friend of mine uses:

• "I think it'd be best if you asked her yourself."
• "That's not my story to tell."

Don't listen to it.
This may be the most challenging. After all, how can you stop someone from talking to you about someone else? While it's true that you can't control what others say, you can control your participation.

Depending on the context, here are some things you can say:

• "This is none of my business."
• "I'm not comfortable with this conversation."
• "I'd rather not talk about Tom when he's not here to speak for himself."
• "I hadn't heard that. Let's go ask him/her about it."
• "Are you going to the workshop Friday?"
• "Excuse me. I need to get back to work."
• "I don't like gossip, and I won't listen to it."

And, given that an ounce of prevention is worth a pound of cure, don't invite the office gossip out to lunch!

I find this poem helps me stay on track:

There's so much good in the worst of us

And so much bad in the best of us,

That it ill behooves any of us

To talk about the rest of us!

What's worked for you? We'd love to know!

The problem with external control

According to William Glasser, author of Choice Theory, all long-term problems are relationship problems: the person has one or more relationships that aren't working as well as they'd like.

And all relationship problems are control problems:

• We're trying to make someone else do what they don't want to do,
• we're trying to prevent someone else from making us do what we don't want to do, or
• we're trying to make each other do what neither wants to do.
  

So why do we do this? Because we think motivation and control are external to us, and we don't understand that we choose everything we do.

The following three beliefs from Choice Theory express this best (italics mine):

FIRST BELIEF: I answer a ringing phone, open the door to a doorbell, stop at a red light, or do countless other things because I am responding to a simple external signal (not because I have chosen to do them).

SECOND BELIEF: I can make other people do what I want them to do even if they do not want to do it. And other people can control how I think, act, and feel.

THIRD BELIEF: It is right, it is even my moral obligation, to ridicule, threaten, or punish those who don't do what I tell them to do or even reward them if it will get them to do what I want. (p. 16)

Attacking, appeasing and avoiding describe general strategies, but there are specific behaviours related to external control which contribute to an emotionally unsafe work environment:

• criticizing
  
• blaming
• complaining
• nagging
• threatening
• punishing
• bribing
  

These behaviours foster gossip, mistrust, fear, manipulation, lying, sabbotage, and cover-ups, to name just a few.

So what's the alternative? It begins with recognizing that

The only behaviour you can control is your own.

And that belief leads to an entirely different set of behaviours which contribute to an emotionally safe work environment:

• supporting
• encouraging
• listening
• accepting
• trusting
• respecting
• negotiating differences

Over the next few weeks, I'll explain these in depth, with lots of stories and examples to illustrate these principles. So stay tuned! We've just begun!

And by all means offer comments and stories of your own!