10 Strategies for Building Strong Therapeutic Relationships
One of my favorite quotes by Dr. Bruce Perry is that “relationships are the agents of change, and the most powerful therapy is human love.” (2006). It’s a powerful statement about the fact that relationships are the cornerstone of healing and in therapy, the relationship between the client and the provider is the core of all healing work.
In this post, I’m talking about the importance of the therapeutic relationship and strategies for building a strong relationship with your clients and their caregivers. This topic will be the subject of many future posts because it’s the anchor of trauma work but this post will be a bit of an intro.
A Little Background
If memory serves me, we weren’t taught anything significant about relationships in OT school. I learned about “therapeutic alliance” and “building rapport.” Discussions were mostly surface level and focused on these being strategies for gaining compliance from clients. The idea being that if you have strong rapport, clients are more likely to listen to you, take your advice, and do the program that you’ve assigned to them and thus, get better. I suppose the obvious subtext was that when you make someone feel safe, seen, heard, and validated, they are more likely to trust that what you’re offering is valuable but I think that explicit sentiment was too “touchy feely” for a medical-model program.
We didn’t talk about what a relationship is, how important relationships have the power to change the way a person sees themselves and the world, for better or for worse. We skipped over discussing the different possibilities in healing that exist in the context of a relationship versus in isolation. It’s ok, this isn’t a complaint about my graduate program, after all it was many years ago now and I hope things have changed for current OT students. I also think these concepts are so complex and for many allied health providers (OTs, SLPs, PTs, etc.) they feel at the fringes of our scope (that’s not true but it’s a conversation for a later post).
Despite my very high quality formal education, I learned what I really needed to know about relationships to become a good therapist (I hope) from training in infant-parent mental health, from working closely with several brilliant and intellectually generous psychotherapists, and most of all from the children and families that I worked with. I got several, sometimes difficult, but very important lessons from parents of kids I treated early on my career that have shaped how I think about therapy.
What is a relationship?
Relationships, as I think about them in my work, are made up of the tangible and intangible stuff between people. They include communication, shared activities, and emotional rupture and repair. They also include what happens within one person as a result of their physical or emotional proximity to another. I think about myself in this way because it’s been reflected back to me by this special person outside myself. I have a sense of myself as being a decent therapist because of what I see in the children and families I work with as a result of our time together. I have a sense of myself as being valuable because my partner is consistently responsive and respectful to me in the course of our relationship.
In next week’s post I’m going to go backwards and talk about how relationships develop and how we can support early childhood-caregiver relationships. (Here it is!) This week, I’m focused on the key elements in the importance of relationships strategies to support the relationships that make early childhood work meaningful!
Why Are Relationships So Important to Early Childhood Work?
Relationships Promote Regulation
When we are in relationship to a trusted, attuned, attentive, non-judgmental other, we are able to be co-regulated. Regulatory state is contagious! As we know, regulation is also required for learning and therapy is all about learning- changing the brain to function in a new or different way that is more satisfying to the client.
Human Beings have Evolved to Learn Skills in the Context of Relationships
People are meant to function in community and we also learn best in community. For example, children do not learn language nearly as efficiently through television or tech viewing than they do from interacting with communicative caregivers. During the early years, children must have an interactive relational partner to actually internalize language in a usable way (Karani, Sher, & Mophosho, 2022).
Relationships Enable us to Grow from Challenges
Challenge is inherent to therapy, without some challenge and stress, no change can occur. Having a partner or team when facing a challenge increases the likelihood that the challenge will result in skill building. Facing challenge alone often results in overwhelm and regression (the opposite of what we want from therapy). Imagine being a child and your therapist gives you some scissors and paper and requires you to sit and practice a new, difficult skill of cutting independently until you get it before moving on to something rewarding. Then imagine you get a new therapist who says, I brought two scissors and we’re going to cut lots of little pieces and make this beautiful collage together! Which scenario seems more likely to result in a child who gains skills quickly and confidently?
Strategies for Relationship-Centered Care
Regardless of discipline, as you’ve seen me say now several times, if you work with young children, your work is and should be centered around relationships. There are some really tangible ways to make this explicit.
Policy & Procedure
Have policies that center your client’s culture and humanity
it’s normal for life to get in the way of therapy, expect and build in the ability to miss or reschedule a few sessions a year
Communication is different across cultures, consider all aspects of a client’s identity when responding to challenging behaviors from them (with the exception for dangerous or threatening behaviors of course)
Relationships with Caregivers
Have regular contact with caregivers throughout treatment and invite them into treatment whenever possible and appropriate
Develop goals in collaboration with caregivers and ensure that your goals reflect the true reasons they entered their child into services
Use understandable language and teaching strategies- avoid jargon without over simplifications. Deliver information in the mode that matches caregivers learning style
Be honest in your communication- if you know or suspect something about a child, include the parent in your processing. Imagine being a caregiver and finding out your child’s therapist thought something about your child months ago but didn’t tell you!
Prioritize the needs of the caregiver in the moment during your meetings while holding long term goals in mind
this is a hard one, insurance billing can make it especially difficult to be responsive to caregiver’s needs.
Therapy may not be the caregiver’s top concern on the day of your meeting and that’s ok sometimes! I once got to a family’s home and as the mother let me in she noticed an eviction notice on their door. We spent the session getting regulated and confirming she had contact for the legal and social work resources she needed and a plan for what to ask them when she called. Is that traditional OT, absolutely not…but was that mom going to take in any new information or strategies about functional communication with her son that day…also no! We left that experience with a stronger alliance and readiness to move forward in our work in the next session.
Relationships with Children
Play! Children communicate through the language of play, in playing with them, they can learn as much about you as you can about them
Be thoughtful in your verbal and non-verbal communication style
Except for newborns and infants who do benefit from parentease, it’s helpful to speak in a normal conversational tone with children. Excessively high pitch, sing-songy language, or over-excitement can be overwhelming, especially for children who are highly stressed or have experienced trauma.
Children know when they are being talked down to. Our tone, volume, and cadence should be clear and easy to understand without being overly childlike or fake.
Your voice tone and volume can also set the tone for a child’s arousal state. When children are with us, we have a great deal of power and control over them as we’re physically bigger and make decisions about where and when they can move out of our space. Using communication and body language that is not overwhelming to each individual child is essential in promoting safety and comfort.
Cultivate genuine interest in their interests and ask thoughtful questions. Instead of repeatedly asking for labeling, try encouraging communication about other things
Instead of “what animal is this?” Try “What do you think this piggy likes for breakfast?”
Instead of “what is this you’re eating?” Try “I can see you love cheese, what if we only ate cheese all the time?!”
Instead of “what color is this?” Try “You’re very focused on this picture you’re drawing, tell me about this blue part of your picture!”
Remind children you’ve been thinking about them since your last meeting.
When working with children who have attachment or separation trauma, I often say things like “Yesterday I had grapes for lunch and it made me think of how much you like grapes. That made me feeling excited to see you soon.”
There is tremendous power in being held in mind by a special person, concrete examples of this are a wonderful therapeutic and relational strategy.
Of course your language will depend on the age and communication abilities of the child you’re with. The idea of playing, monitoring your tone and style of communication, cultivating interest in them, and holding them in mind are key to relationships with any child!
What other strategies do you have for building strong relationships with your clients? I’d love to hear from you, get in touch on instagram or send me an email!
Resources & References
Karani NF, Sher J, Mophosho M. The influence of screen time on children's language development: A scoping review. S Afr J Commun Disord. 2022 Feb 9;69(1):e1-e7. doi: 10.4102/sajcd.v69i1.825. PMID: 35144436; PMCID: PMC8905397.
Perry, B. D., & Szalavitz, M. (2006). The boy who was raised as a dog and other stories from a child psychiatrist's notebook: What traumatized children can teach us about loss, love, and healing. Basic Books.
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