Rapport and Relationships in Clinical Interactions : Topics in Language Disorders

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Rapport and Relationships in Clinical Interactions

Editor(s): Duchan, Judith Felson; Kovarsky, Dana Issue Co-Editors

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Topics in Language Disorders 31(4):p 297-299, October/December 2011. | DOI: 10.1097/TLD.0b013e31823baf91
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Rapport has been described as “the relative harmony and smoothness of relations between people” (Spencer-Oatey, 2005, p. 96). It is a highly valued part of clinical practice, but it is often talked about as secondary in importance when compared to the “real work” of therapy. Indeed, rapport is often viewed as an exchange of pleasantries. It is seen as something to be fostered early in a therapy session, so that the more important therapy goals can be more easily accomplished.

One reason for rapport's peripheral role in communication has to do with our way of conceptualizing communication. For example, there is little room for considering rapport within a framework that treats communication as a linear series of messages being passed along a conduit between senders and receivers. In this “conduit metaphor” (Reddy, 1979), messages are seen as being made up of encapsulated thoughts sent along a pipeline from the lips of a speaker to the ears of a hearer.

The conduit metaphor has had a powerful influence on how clinicians see their role (Duchan, 2011). If communication is depicted as message passing, then it follows that the therapist's task is to determine where in the message the communication problem arises. For example, diagnoses often involve determining which parts of the message are problematic (phonology, morphology, syntax, semantics, pragmatics), and therapies often are designed to remediate the problematic domains. That is to say, the clinical enterprise involves finding and fixing the discrete aspects of psycholinguistic information that disrupt the client's ability to create messages and pass them to conversational partners (Kovarsky & Walsh, 2011). Rapport only becomes significant in this framework when it is problematic, or negative (see Kovarsky, Schiemer, & Murray, 2011 for a discussion of negative rapport). Put another way, clinicians have typically focused on rapport when problems with it threaten to undermine therapists' efforts to do the work of identifying and repairing the client's ability to transmit messages.

In this issue of Topics in Language Disorders (Volume 31, Number 4), the authors call for another view of communication: one that is interactive, coconstructed, and emotionally grounded, and one in which rapport plays an integral role. In so doing, they challenge the message-passing metaphor and other prevailing conceptions of communication that have marginalized the role of rapport.

Furthermore, rapport is regarded here as a key to the meaning-making that goes on between interactive partners. This collaborative depiction simultaneously expands upon and challenges a traditional semantic view in which meaning is seen as being primarily linguistically determined. Instead, meaning-making in interaction involves the constant negotiation of interpersonal and emotional relationships that take place in discourse. This places rapport in a central role in communication rather than as a mere lubricant for the therapy process. It follows also from this wider collaborative view of meaning that miscommunications can occur as part of rapport building and can take place even when the linguistic content of verbal messages are successfully conveyed (Grimshaw, 1980; Varonis & Gass, 1985).

Because ongoing meaning-making is a key to success of therapy as well as communicative success in other kinds of interactions, it follows that rapport needs to be studied as it is happening in clinical discourse. Discourse analysis offers our authors a way to examine and evaluate how rapport is being managed and achieved by participants in the course of therapy interactions. Simmons-Mackie and Damico (2011), for example, identify occasions of missed opportunities in which one partner fails to pick up on the emotionally laden overtures of another.

Kovarsky et al. (2011) find and analyze those occasions in which one partner does something to jeopardize positive rapport-making.

Duchan (2011) sets the scene for the issue by discussing ways that rapport in relationships have been construed. She identifies and describes ways that prevailing conceptual frameworks, such as the conduit model, have forced us into a sort of hide-and-seek activity where we must disregard or work around our conceptual frameworks if we want to attend to the emotional side of clinical interactions.

Duchan (2011) also identifies various frameworks that have served to reveal rather than hide emotional interactions between clinicians and their clients. By viewing interactions as ways that people “tune into” one another, for example, investigators can discover how this is attunement is achieved. Attunement can be signaled interactionally, by nonverbal resonances as when partners respond to one another's rhythms, sounds, and vocal and movement intensities. Verbal attunement is also central to rapport building as interactants alter their dialogue to resonate with the contributions of their partners.

In the next article in this four-part series, Fourie, Crowley, and Oliviera (2011) look at clinical relationships from the perspective of children who have been in therapy. These authors uncover what children between 9 and 14 years of age value about their clinicians and how the children remember clinical experiences over time.

The children were sometimes better able to remember the clinician's positive physical and personality traits and their own experience of having fun in therapy than they were able to describe the nature of their therapy or their therapy successes. Similarly, some children commented on their sense of power and powerlessness as a client—an indicator that power, like rapport, is located in the relationship, that it is negotiated, and that therapy works best when the clients feel empowered.

Like other articles in this issue, the findings of Fourie et al. (2011) reveal that rapport matters when evaluating the goals and successes of therapy. For children, their sense of what constituted a positive outcome in therapy was inextricably linked to the nature of their interpersonal relationships with their therapists.

Kovarsky et al. (2011), in the third article in this issue, identify what they call uncomfortable moments in interactions. In so doing, they show how interactional difficulties can threaten social relationships and how interactional partners who want to maintain rapport feel a need to manage those difficulties. When detailing clinical relationships through discourse analysis, these authors consider how participants orient themselves to one another, both positively and negatively. In situations that involve positive rapport, interlocutors seek to strengthen, maintain, or protect harmonious relations. In negative rapport situations, they may actually challenge or derail positive discourse resonances that can serve to maintain rapport.

Simmons-Mackie and Damico (2011) round out this interwoven series of articles by identifying how clinicians manage the discourse of clinical interactions so as to avoid talking about the emotional and personal side of their clients' lives, thereby missing opportunities to create a deeper kind of rapport. Their excerpts of “counseling opportunities” that occur in the course of clinical interactions show how clinicians systematically subvert the solicitations of their clients to explore emotional content. In examples shared by Simmons-Mackie and Damico, clinicians maintain an emotional reserve, failing to resonate with their clients' emotional displays, and failing to help their clients explore their emotions about problems they raise in the course of therapy sessions.

These two authors then identify the discourse strategies used by clinicians that seem to be designed to avoid talk about emotions. The strategies include things such as sticking to the “facts” or “known information,” using humor to deflect emotion, and diverting attention away from the emotional issue and towards therapy tasks.

This is issue of TLD on rapport and relationships in clinical interactions can be read as a call for change. When taken together, the articles provide an alternative to how clinical relationships have traditionally been depicted in the speech-language pathology literature and in clinical practice. They do this in several ways:

  • By depicting rapport as an ongoing process of meaning-making, the authors raise it in status from something established early in therapy sessions to something that is key to what ensues throughout therapy sessions.
  • By depicting rapport as co-constructed and interactive, the authors no longer make the clinician the one who is solely responsible for “rapport building.” Instead, rapport grows out of ongoing negotiations between the clinician and the client.
  • By seeing rapport as part of communication, the authors suggest ways for clinicians to do a better job in “counseling” clients and managing communication breakdowns associated with breaches in relationships.

Finally, the authors in this issue provide ways that this ephemeral nature of rapport can be made more concrete and tangible. They do this by making use of conceptual schemas of communication that better reveal rapport, by using discourse analysis to illuminate how rapport is being negotiated in the course of interactions, and by taking the clients' perspective on social relationships to evaluate overall therapy success.

—Judith Felson Duchan

—Dana Kovarsky

Issue Co-Editors


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.
Grimshaw A. (1980). Mishearings, misunderstandings, and other nonsuccesses in talk: A plea for redress of speaker-oriented bias. Sociological Inquiry, 50, 31–74.
Kovarsky D., Walsh I. (2011). The discursive construction of language disorders. In Candlin C. N., Crichton J. (Eds.), Discourses of deficit (pp. 195–214). New York: Palgrave Macmillan.
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.
Reddy M. (1979). The conduit metaphor. In Ortony A. (Ed.), Metaphor and thought (pp. 284–324). New York: Cambridge University Press.
Simmons-Mackie N., Damico J. S. (2011). Counseling and aphasia: Missed opportunities. Topics in Language Disorders, 31(4), 336–351.
Spencer-Oatey H. (2005): (Im)politeness, face and perceptions of rapport: Unpackaging their bases and interrelationships. Journal of Politeness Research, 1(1), 95–119.
Tannen D. (1989). Talking voices. New York: Cambridge University Press.
    Varonis E., Gass S. (1985). Miscommunication in native/nonnative conversation. Language in Society, 14, 327–343.
    © 2011 Lippincott Williams & Wilkins