The role of rapport

In psychotherapy a great deal of importance is placed on rapport, on the therapeutic bond. The problem is, for parents, that we know pretty early on that the rapport between a therapist and our child is at least partially based on a third party: the ED. We know that the person wearing our child's face is is ED, and we grow frustrated with therapists listening to and BELIEVING ED's words. We are especially dumbfounded when ED is quoted back to us as if he was a reliable source about our family.

Even without a lot of experience with this illness, parents are quick to realize that our own perceptions, investments, and authority are now being bypassed. We object to another adult inserting him or herself into our families in this way, and we are alienated and disturbed by this empowerment of an irrational young person. Sometimes we get hopping mad!

Parental indignation must be really hard for therapists; I sympathize. When your motivation for going into the profession, your training, and your natural human instinct to help others is all being questioned by this person who has no prior training or understanding of the illness. Where a parent arrives with some Internet printouts and new ideas. When parents like myself incite other parents to "ask good questions" instead of just answering them.

Psychotherapists know that their own motives are good, that their training is extensive, that the therapeutic process is not inherently scary and that it often works miracles. But parents come into that relationship with fear, distrust, and an extraordinary investment in this ONE child and this ONE recovery. Unlike professionals trained for years and motivated to be there, how many parents ever really thought we'd be in that room?

And what parent is initially prepared for developing rapport with a stranger we never thought we'd need?


  1. I think one of the problems is that the studies showing an association between what's called "therapeutic alliance" and successful treatment of eating disorders have been misinterpreted by some clinicians. Those studies have generally found that when patients who have been successfully treated are interviewed later, they point to a rapport with their therapist as a major factor in their recovery. Unfortunately, though, we don't know whether the rapport causes the recovery, or the recovery causes the rapport. So, its not clear that rapport for its own sake is a therapeutic advantage, especially if the rapport consists of enabling, not challenging, the eating disordered thoughts and behaviors.
    When my daughter was first diagnosed with anorexia, she received a lot of talk therapy and not enough food. She became more and more ill, both medically and mentally. When the treatment plan was switched to more food, and less talk, she got better. I'm not saying talk therapy has no role, just that rapport with a talk therapist isn't, alone, enough.

  2. On the other hand if the therapist is the main driver behind the treatment (as he or she is in Maudsley for example) SOMEONE in the family has to develop at least a tolerance for him or her!
    I agree so much with your last sentence Laura - perhaps even worse when it's a stranger you were always dreading needing?

  3. Do the majority of individual therapists eternalize the illness when engaging with a patient or do they believe the person sitting in their office is cognitively aware and capable of understanding the complexities of the illness?

    Not only are parents and patients burden with the stigma from the general population but also from some "experts".

  4. I'm pretty sure we just DON'T know what the active agents are, and that beyond a certain level we probably can't really measure it. Therapy is too personal both for the patient and the clinician.

    How do you manualize empathy, intuition, or even the skilled application of manualized treatment?

  5. There are tools for assessing therapeutic alliance are published articles on therapeutic alliance in FBT for AN (Pereira et al, 2006) and BN (Zaitsoff et al, 2008). The question of whether manualized FBT can be disseminated was looked (Loeb et al, 2007) in an open trial. The MP bibliography has some good resources.


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