Practitioner/Patient Rapport, Part III

By Neil Gumenick, MAc (UK), LAc, Dipl. Ac

Rapport places us at one with the body, mind, and spirit of another. Rapport is critical to our practice and to effective healing because only when our patients trust us and feel safe with us, will they open up to reveal who they are, what they need, and become receptive to what we have to give. However much information we may have about a particular ailment or pain, unless we engage the unique individual who has the ailment, we do not have rapport.

Creating rapport is our job, not the responsibility of the patient. There is no automatic formula that can guarantee rapport between practitioner and patient. No two people, even those with the same symptoms, are the same. What one patient may love will infuriate another. Therefore, we cannot interact in the same manner with different people and expect to have the same rapport with both. Rather, we must be willing and able to move ourselves to resonate with the wants and needs of the patient. We must stay conscious of everything we say and do in the treatment room - especially how we say and do things, and how the patient responds. This involves being comfortable with the emotional expression of all five elements. To the extent that we are able to "roll" with our patient's unique expressions of joy, sympathy, grief, fear, and anger, we are able to make rapport with whoever comes to us - whatever they bring.

Neither needles nor herbs can do it all. When we, ourselves, become part of the medicine, our work will reach far deeper levels of healing than is possible by technique alone. Though it may not be the stated reason for their visit, patients come to us, as well, for a comforting touch, a reassuring hand, to be heard, understood, and acknowledged, for firm direction, for warmth and laughter. How are we to know? Our senses, not our heads, perceive what is being asked for. The perception of the need and our response become a seamless flow of interaction, giving us real unity with another. We know who the patient is and what he or she truly needs because we feel it. We experience it in our body through our senses.

In developing the skills of rapport, we must be willing to leave our own comfort zone. This can be frightening. Like our patients, we, too, wear "masks" to which we have grown accustomed. Often, the wearing of these is not a conscious choice. It feels to be "just the way we are." These are expressions of our own elemental imbalances, our stuck places, causing us to overly exhibit or repress certain emotions. What this means is that we are unavailable to other ways of being, reacting, and expressing. We are, therefore, unavailable to sense or resonate with the needs of many patients, particularly those who are unlike ourselves.

Consider a child below the age of one, whose expression is free and spontaneous, without an internal censor or critic. Very young children sense and react. Only when they have been conditioned and programmed to deny their instinctual needs, behave themselves, and avoid punishment do their senses begin to shut down. They begin to live in their heads. We all had our sensory gifts once. We learned to shut ourselves down, but we can choose to turn ourselves back on.

Everything we say and do elicits evaluation and reaction by the patient, consciously or unconsciously. When a patient does not like our approach (or any other aspect of our interaction), he or she will let us know in a multiplicity of ways. We then have to change immediately. In Classical Five-Element practice, our attention to what a patient likes and dislikes, welcomes and rejects, serves as a powerful tool, and rewards us with a wealth of diagnostic information.

In this system of acupuncture, we consider the presenting symptoms in a vastly different context from the need of the patient. Symptoms are distress signals from the body, mind, or spirit, saying, in essence, "Help me!" Of course, all patients want to be rid of their symptoms and we want this for them, but we do not rely on the symptoms to lead us to the cause. Any symptom can be the result of imbalance in any of the five elements or any of the twelve officials (organs/functions). To ascertain the cause, we have to know who this unique individual is that has these symptoms and why he or she has them. How are the symptoms affecting the patient's mind and spirit? What part has the patient's mind and spirit played in creating the symptoms or compromised the body's innate power to heal? The answers to these questions are perceived only in the presence of the patient. Rapport is what makes this inquiry possible and productive.

In Classical Five-Element Acupuncture, the underlying imbalance, or causative factor, is revealed by the color in specific areas of the face, the sound of the voice, the expression of the emotions, and the odor of the body. Through interaction with the patient, we determine the level of the underlying imbalance (mind or spirit) and what assistance is needed at these levels, delivered by the use of appropriate points for their spiritual connotations. Through pulse diagnosis, we perceive the relative state of energy in each of the twelve officials (organs/functions) and the presence of energetic blocks. From these perceptions of the patient as a whole, we can plan a treatment because we understand the significance of every part of the patient, including the presenting symptoms.

How Do We Do it?

While there are no absolutes or rapport "checklists," the following are suggestions for optimizing the environment in which rapport can be achieved:

Observe the Patient Prior to Contact

If possible, watch the patient before he or she is aware of being observed. If a patient, for example, struggles to exit his car, staggers to the office door grimacing in pain, and on entering, straightens up and puts on a brave face, we know that this is a person who is hiding his pain. Another may exaggerate his symptoms on being observed. Another patient may angrily slam the car door, walk up the path to our front door snarling and agitated only to enter the office smiling as if she hadn't a care in the world. Another may spend minutes in the car drying his tears before entering. We need not confront these inconsistencies straight away. We have to make rapport first and foremost, but all of these expressions give us valuable information about who the patient is, what they are going through, and how we must approach them.

Make Use of the Initial Greeting to Initiate Rapport

The time to make rapport begins right at the beginning, long before we ask the first question about why the patient has come for treatment. The first physical contact with patients is generally a greeting handshake and provides a wonderful opportunity to turn our sensing meters on. Aside from sensing the physical characteristics (i.e. skin temperature, texture, degrees of wetness or dryness, etc.) we must feel how they take and hold our hand. Do they shake it vigorously? Do they cling? Do they barely make contact at all? Is the hand lifeless or trembling? Do they take their hand away as quickly as possible? Do they clasp our hand with both of theirs and pull us to them? Do they try to crush our hand in a show of strength? All of these possibilities (and many more) tell us things about individual patients more truthfully than their words. The mouth may be saying, "Glad to meet you," but the hand may be saying, "I'm scared to death to be here."

Our response must be to the deeper need, not the mask. If we perceive a patient's fear, our words, facial expression, eyes, tone of voice, and touch must all convey reassurance in response to the fear. Admittedly, it is appropriate for patients coming for acupuncture for the first time to have some fear and apprehension. But, if this fear persists throughout the entire examination, regardless of what is being discussed, we will be "jarred" by the inappropriate expression. Does the patient continually need reassuring or reject this emotion and express the imbalance as fearlessness? The same "jarring" will be felt if we are sensing instruments, clear of our own obscurations, in the presence of any inappropriate emotion. Sensing the underlying need, we allow our whole selves to respond to the need.

Intensify Rapport-Creating Efforts in the Treatment Room

Having begun the process of establishing rapport with our initial greeting, we now use every opportunity at hand to sustain our momentum. In my office, I have two identical chairs, one for the patient, the other for myself, from which we begin the information-gathering part of the exam. This arrangement expresses equality and does not intimidate or put the patient at a psychological disadvantage. The chairs are angled slightly toward each other, without a barrier (such as a desk) between us. This position does not force direct eye contact, which may be too confrontational for some patients, but allows for it to occur spontaneously. In this position, I can also, as appropriate, make physical contact with the patient. I can easily take a hand, read the pulses, palpate a painful area, offer support, warmth, reassurance, comfort, compassion, etc. How a patient responds to touch gives much more valuable information about him or her than words, if our sensing meters are turned on.

Some patients will make themselves right at home and take a seat. Others will need an invitation to do so. Still others will need to be told where to sit. Some will argue, "Why can't I sit there?" Some will move their chair closer or further away or angle it so that they are looking directly at us. All of these things tell us about the patient and what he or she needs. Some are telling us, "I can't handle too much closeness. I need space. Keep your distance," Others tell us, "I'm ready and I'm an open book. Let's get down to it!" Still others tell us, "I'm so weak and need someone I can lean on." Obviously, there are as many variations as there are patients. We may not get the full message simply from how they take a seat. The point is that there is no detail so small as to be insignificant. The patient is giving us the information we need every moment.

Use Small Talk to Create Safety and to Gain Insight

Many patients need to be put at ease with some small talk. We can use what we already know about the patient to initiate conversation. If the patient has come from a long distance, we can ask about the journey. If the patient has been on the waiting list for some time, we can express how glad we are to finally meet. We can chat about the weather, any problems finding the office, parking, etc. We can ask if the room temperature is OK and offer to turn up the heat, a blanket, etc., if they would like a glass of water, if they are comfortable in the chair or would prefer to lie on the table. All of this expresses our concern and care for the patient.

This small talk is not idle or meaningless. It is a non-threatening way to interact, increase rapport, and take in the patient as a whole. As we talk, we note if the patient draws us in or keeps us at a distance. Is he comfortable with joviality or unable to smile? Does he elicit our sympathy? Is he able or unable to take in our caring attentions? Is he put at ease, or made anxious or frustrated with small talk?

Deepen Rapport through Skillful Probing

The transition from small talk to questioning about the reason for the patient's visit should be so seamless that the patient should not sense that "the examination has begun." Otherwise, the rapport we have created may be broken and the mask may go up. An examination is not a performance unless our own anxieties make it so. Patients pick this up immediately and what was a simple, natural interaction devolves into a question-answer interrogation. There are specific areas into which we must inquire, but to achieve rapport, we must reach the whole person, not simply the information about them. How we ask and how they respond are more important than what we ask. If the rapport is there, patients will tell us, verbally and non-verbally, what we need to know.

Generally, we do not ask questions that elicit "yes/no" or other one-word answers. "Tell me about your...." is much more inviting for the patient to freely express than asking "How is your...?" Most people will answer such a question with, "Fine." Do not simply accept answers at face value and move on. "Fine" is generally a flippant, unconscious, and meaningless answer. I have seen patients who have had one bowel movement per week for years and believed that to be "fine." Also, there may be a wealth of information beneath the one-word answer that the patient is dying to tell, but unless we question more deeply, we may never know. It may seem to the patient that we are simply not interested.

Therefore, ask further, "What do you mean by 'fine?'" or "Tell me more about that." If there really is nothing more to be said on a given subject, we will feel it and move to something else. If there is more, but the patient does not wish to go into it, he may or may not reveal it in words, but we will sense the resistance. We may feel it in the way the patient takes our hand, in his breathing, facial expression, etc. We register this and move on. If, after several treatments, the patient brings the subject up willingly, or accepts our bringing it up, responds differently in his body, we have evidence that our rapport has increased and that we are reaching the patient at a deeper level. The initial examination really never ends. Each session provides numerous opportunities to perceive what the patient needs and assess what changes have taken place.

Observe Everything

Patients are constantly giving us clues about their condition. Body language is a rich source of diagnostic information, as well. We observe how the patient moves: gracefully and relaxed? Haltingly? With timidity? Overly rigid and controlled? Carelessly? Assertively? Does the patient sit with arms or legs crossed or open? Lean toward or away from us? What creates change? If we assist the patient to the table, how does he or she react to our assistance? Lean on us for support? Stiffen? Pull away? Insist on doing it alone?

Likewise, the patient's facial expression reveals so much to our close attention. Is the face tight and intense, the jaw set and determined? Is it welcoming? Can the patient's eyes meet ours? Do they stare us down, avoid contact, soften or harden? Does their body tense, pull away, relax, or pull us in closer? Does their breathing relax, quicken, or stop altogether? What happens to the sound of their voice? What is the emotion behind the words? Does the content match the way it is expressed?

What precipitates changes in all of these largely unconscious signals our patients use to tell us who they are? We will never know unless we set about to deliberately trigger such changes. We must interplay with the patient constantly, changing the sound of our own voice, the way we touch, our pace, our physical proximity, even what we communicate with our eyes. Sometimes, we simply follow the patient's lead. Sometimes, we must initiate, providing the emotional environment for the patient to react to us. We then feel their reaction. We respond to it.

We feel the patient's reaction to all of the forgoing and to all that follows during treatment. The more we work at awakening our senses, the more we will perceive and the easier it will be for us to adjust to our patient's needs and temperament, as needed. Rapport creates its own dance. We know when we are in sync with our partner and when we are not. How do we know? We feel it in our bodies. We make the adjustment. We feel the change.

Remain Alert to Typical Obstacles to Establishing Rapport: Apply the Appropriate Cure When They Arise

Head as Obstacle

One way we can disconnect from our senses and let our heads take over is doing the entire examination by rote: having a set list of questions, which we routinely ask, paying no attention to how we ask or to how the patient answers. We are simply interested in the information, the data. Thus, we have one head asking, another head answering. As we have seen, we need information, but information alone will not reveal who the patient is. We cannot have rapport with information, only with a human being.

Another way our heads get in the way is by constant internal rehearsal of what we are going to say or do before we act and critiquing after the fact. This puts us either in the future or the past, not in the present moment, where it is all really happening. Why do we do this? Usually, it is because we are trying too hard to get it right, trying to be seen as good practitioners worthy of our fees, trying to gain approval. We do not trust our senses to simply receive, so we struggle to "figure it out" as we go: thinking, plotting, analyzing, categorizing, and becoming more and more tense. Filled with such active chatter, we can sense virtually nothing. Like a bell stuffed with cotton, we are not free to vibrate in response to another bell ringing nearby. Empty, we are receptive to the vibration of another. We can notice how we are vibrating, resonating, how we are "jarred", how we are moved to respond to our patient's presence. Allowing ourselves to simply "be" with a patient creates within us the capacity for the authentic response that emerges naturally from true rapport.

Body as Cure

When we have disrupted true rapport by retreating to our heads, the way back into our sensing instruments (our bodies) is to do something physical.

Breathe! Take a conscious breath.

Move! Change position. Make or change physical contact. Take the patient's hand. Sit him up. Lie her down. We let our touch be an extension of our words and intention.

Get curious! Instead of wondering what to say next, we attend to our bodily awareness, and indulge our natural curiosity. We take advantage of our first row center seat view into the life of this unique human being before us, and we simply ask what we want to know. It is an utterly fascinating experience. If we allow ourselves to get involved fully, the interaction rolls naturally and effortlessly.

Developing Skills Essential to Practitioner/Patient Rapport

In order to be effective, it is not necessary that our patients accept or believe in acupuncture or Oriental medical concepts. It is necessary that they feel heard, understood, and cared for by us. The more we empty ourselves of ourselves and our preconceptions, the more we can be fully present to perceive and receive our patients. The choice to develop our skills in rapport-making is, at heart, a courageous choice to stretch beyond our self-imposed limitations. This is the essence of our growth as practitioners.

In Classical Five-Element Acupuncture training, we practice rapport-making with each other outside of an actual treatment situation so that the pressure is lifted. In pairs, role-play with one being the "practitioner" and another the "patient." Our practice partner gives feedback as to how he or she felt as our "patient." We learn about ourselves through the eyes of others. Were we too distant or too close? Did we overwhelm our partner? Did we fire questions like a military interrogation? Did we take the time to listen? Were we smothering? Frightening? Did we go too fast? Not fast enough? Were we overly reassuring when it wasn't wanted or needed? Dictatorial when softness was needed? Too soft? Was our physical contact too much or not enough? We have fun with this process and laugh at our many mistakes.

When we can laugh at our own egos and see through our clinging to image, our efforts to look good, to be right, and our fear of looking foolish, the whole false-self structure falls away, revealing what is real and allowing us to perceive it and be affected by it. We are then free to be ourselves, free to respond naturally and effortlessly to the world (and the patients) around us moment by moment. Freed now to perceive the brokenness at the core, we can understand the brokenness of the parts. Sensing from our whole selves, we can know exactly what is needed from our needles and from ourselves to assist nature to restore wholeness in another.

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