Getting to know you,
Getting to know all about you.
Getting to like you, Getting to hope you like me.
Music: Richard Rodgers
Lyrics: Oscar Hammerstein II*
These light-hearted “Getting to know you” lyrics were written by Oscar Hammerstein for music by Richard Rodgers. They are spoken and sung by the character, Anna, in The King and I as she is preparing to teach the King's many children. The song came to mind when I was looking for a way to introduce this fascinating issue of Topics in Language Disorders (Vol. 31, No. 4), by issue editors, Dana Kovarsky and Judith Duchan, on the topic of “Rapport and Relationships in Clinical Interactions.” Initially, I worried that the lyrics might be too light-hearted to do justice to such an important and weighty topic. Certainly, being “liked” is not what clinical rapport is all about, is it? On the other hand, liking and being liked, according to at least one article in this issue (Fourie, Crowley, & Oliviera, 2011), is not unimportant, particularly in the minds of children. Furthermore, in this era of Facebook, “liking” something has acquired a whole new meaning.
So I delved further to retrieve the full set of lyrics for “Getting to Know You.” Without repeating all of them, two other stanzas struck me as particularly relevant to the topic of establishing rapport, not only between teachers and pupils across a cultural divide (i.e., Anna and the children of the King of Siam), but also between clinicians and clients who are strangers coming together in the context of therapeutic activities. Consider first the stanza spoken by Anna before transitioning into song:
[Spoken] It's a very ancient saying,
But a true and honest thought,
That if you become a teacher,
By your pupils you'll be taught.
These words capture a central theme across the four invited articles that make up Kovarsky and Duchan's (2011) topical issue. To be taught by one's pupils (clients in this case—adults, children, and family members), one must pay close attention to what those “pupils” already know, while seeking to understand the essence of who they are and what matters most to them. Clinicians can do this by listening sincerely to clients' verbal and nonverbal messages. Are they anxious about something? Are they feeling emotions that would help the clinician understand their strengths and needs on a different level? Is it “unprofessional” to feel emotions along with one's clients?
In her lead article, Duchan (2011) urges readers to reconsider how clinicians are socialized through the medical model to view expression of emotions as a problem to be dealt with (or avoided) rather than a privileged part of a growing relationship. As Duchan cautions readers, negotiating the emotional space in a relationship, which is what rapport is all about, cannot be distilled to a model of boxes and arrows. Rather, Duchan highlights literature that contrasts with predominant concepts of emotions as problems, showing how alternative concepts can lead speech–language pathologists to a more helpful view. Specifically, Duchan presents the case for emotions to be viewed as a key component of the relationship. To be responsive to clients' needs and help them address their most pressing issues, clinicians must be willing to be taught by clients and learn what it means to be in their shoes.
Simmons-Mackie and Damico (2011) provide qualitative evidence of how clinicians might overlook, or even actively avoid, emotionally toned moments in clinical interactions. Their article addresses missed opportunities for clinicians to engage fully with adults with aphasia who are conveying emotion. These authors encourage speech–language pathologists to work with clients to address clients' areas of greatest concern. Again, the skill of listening in the deepest sense—not just receiving the message, which, as Duchan reminds readers, is part of the outmoded conduit metaphor of communication—involves engagement in co-constructive meaning making. This process is essential to helping clients think about and communicate matters of the greatest concern to them. Simmons-Mackie and Damico challenge readers (clinicians, professors, students, and researchers) to take another look at the meaning of competence in the clinical role of counseling. That role includes being emotionally and cognitively available to clients who are concerned about coping with altered life circumstances, beyond learning to talk better. Being relevant to clients' communicative needs can lead to “getting down to work” in more ways than one, including using clinical skills to support more effective communication for addressing issues clients prioritize.
It is important to note that the examples shared by Simmons-Mackie and Damico (2011) come from experienced clinicians as well as from student clinicians. This illustrates that, when emotion enters the session, “knowing what to say” is a challenge for many clinicians, not just novices. These examples also remind readers that knowing what to say at uncomfortable moments is a skill that must be cultivated just like any other clinical competence. Once again, Duchan's (2011) opening piece can be tapped for insights. She reminds readers of Rogerian counseling principles. That is, rather than deflecting the uncomfortable moment with humor or by “getting down to work” when clinicians are uncertain what to say, as in examples shared by Simmons-Mackie and Damico, clinicians might paraphrase and reflect their clients' verbal and nonverbal meaning while checking to be sure the co-constructed messages have the meaning the client intended. To become a master clinician, one must be willing to risk uncertainty along with the client, enter a shared emotional space, and build mutual trust in the potential for the therapeutic relationship to engender communicative resources and strategies in clients for addressing concerns that extend beyond the clinic room.
Relationship building also can mean simply listening and conveying empathy about a problem that may not be solvable or within the clinician's expertise. This can be a particular challenge for clinicians who are fix-it oriented and problem solvers by nature. As I was preparing to write this column, a mother of a child with autism e-mailed me a question about my textbook (Nelson, 2010). She was trying to locate the quotation, “Problems are not just within children, and neither are the solutions” (p. 22), which had been particularly meaningful to her. Her asking about that was particularly meaningful to me; it also reminded me of the need to be “in this together.” Part of that message is that the therapeutic enterprise of making a difference that matters is a collaborative one. It is built on and enhanced by relationships that cross systemic boundaries and may include referrals to professionals across disciplines.
Qualitative research methodologies, particularly phenomenological ones, offer further opportunities to be taught by those we seek to understand. Rarely have children been asked about their perceptions of the therapeutic process. In their article, Fourie et al. (2011) begin to close this gap by reporting qualitative evidence from interviews of children who are asked to share their views on experiences with their speech–language clinicians. Fourie and his student-researcher colleagues adopt a definition that characterizes emotional bonding as the essence of the therapeutic relationship and situate it within a model of therapeutic relationships that comprises goals and tasks along with bonding.
Through phenomenological analysis of qualitative interviews with children receiving speech–language services, Fourie and his colleagues (2011) provide insights into the children's perceptions of the clinical process. The findings highlight the importance of factors such as routines, trust, fun, rewards, and other features that make clinicians and services likeable and a safe context for children to take risks and try new things. In the words of one of the child participants, such factors can keep therapy from becoming, “dull, dull, dull.”
The theme of “knowing what to say” relates to another stanza of Anna's song from The King and I. This one connects the building of new relationships directly to communication competence and confidence. Hammerstein said it better:
Getting to know you,
Getting to feel free and easy
When I am with you,
Getting to know what to say
“Getting to know what to say” captures a central purpose of speech–language pathology services—helping clients know what to say and how to say it. In this issue of TLD, Kovarsky and Duchan (2011) and their invited authors remind readers that clinicians are not always sure what to say themselves. The song lyrics in this stanza are consistent with the issue's theme that knowing what to say is a product of a relationship, not a precursor to one.
Also within this issue, Kovarsky, Schiemer, and Murray (2011) make a particularly thought-provoking venture into the uncharted territory of awkward or uncomfortable moments in communicative interactions. As a major proponent of contextualized service delivery, I struggled with my reactions to the rich qualitative data incorporated in this article. The “Gateway Cafe” described by the authors was devised as a nonclinical, community-based program. Although it was affiliated with a university training program, it functioned as a “recreational gathering place for any adult with traumatic brain injury who wished to attend” (p. 325). The program was staffed by speech–language pathology students, but they were not working in the context of clinically supervised therapy sessions. This added interesting contextual factors to the interactions that ensued, as analyzed by Kovarsky and his colleagues. The authors described uncomfortable moments arising in this context from the use of socially insensitive humor by one of the participants with traumatic brain injury, who was drawing from his stand-up comedy routine but missing cues from the communicative interactants about how uncomfortable it made them. Beyond the authors' interpretations, the samples raise some broadly challenging questions about the need for clarity in the roles of participants in quasi-clinical contexts. Did the student staff members have a responsibility to provide therapeutic guidance about the nature of the client's communicative insensitivity? Should they have reacted as they would (and did) as social peers in an authentic community setting? Should they have ignored the communicative inappropriateness? Although there are no clear answers to these questions, they are thought-provoking. In fact, since I have been the editor of TLD, I can think of no issue that has been more thought-provoking than this one.
Beyond the invited content, this issue of TLD includes a “bonus” article by Sohlberg, Todis, Fickas, and Ehlhardt (2011). Although this article was submitted outside of the issue editors' concepts for the issue on rapport and relationships, it addresses another type of relationship—that between students with disabilities and their peers. In this case, the authors report research on the introduction of e-mail communication supports for 11 middle school students. An interesting finding was that, over the 12-week project, a total of 1,323 e-mails was sent. The sheer volume of these messages is an impressive reminder of the power of relationships for motivating communication and enhancing its relevance to clients' goals and priorities.
In summary, this fascinating issue is packed with thought-provoking content. I recommend it to clinicians, students, professors, and researchers alike. Whether all will agree with the authors' interpretations is yet to be determined. Regardless, I guarantee that this issue will stimulate reflection on the nature of rapport and relationships in clinical interventions. I invite readers to share interpretations through the social network links available on our Web site, www.topicsinlanguagedisorders.com.
— Nickola Wolf Nelson, PhD
Duchan J. F. (2011). How conceptual frameworks influence discovery and depictions of emotions in clinical relationships. Topics in Language Disorders, 31(4), 300–309.
Fourie R., Crowley N., Oliviera A. (2011). A qualitative exploration of therapeutic relationships from the perspective of six children receiving speech–language therapy. Topics in Language Disorders, 31(4), 310–324.
Kovarsky D., Duchan J. (2011). Foreword: Rapport and relationships in clinical interactions. Topics in Language Disorders, 31(4), 297–299.
Kovarsky D., Schiemer C., Murray A. (2011). Humor, rapport, and uncomfortable moments in interactions with adults with traumatic brain injury. Topics in Language Disorders, 31(4), 325–335.
Nelson N. W. (2010). Language and literacy disorders: Infancy through adolescence. Boston, MA: Allyn & Bacon.
Simmons-Mackie N., Damico J. S. (2011). Counseling and aphasia treatment: Missed opportunities. Topics in Language Disorders, 31(4), 336–351.
Sohlberg M. M., Todis B., Fickas S., Ehlhardt L. (2011). Analysis of email produced by middle school students with disabilities using accessible interfaces: An exploratory study. Topics in Language Disorders, 31(4), 352–372.
* Downloaded October 11, 2011, from http://www.all-musicals.com/lyrics/kingandi/gettingtoknowyou.htm.
* The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article.