Establishing a Therapeutic Alliance with Clients

For the last few months, the tables have been turned on me. Instead of playing the familiar and comfortable role of dietitian, I have been the patient. Broken bones forced me to take a time-out from my professional life to focus on my own health.

Those who know me well knew how much I did not want to have orthopedic surgery. I would have done anything to avoid it. But the truth was I had to have it. I felt trapped and, quite frankly, scared. Thoughts of potential postoperative complications and rehabilitation were troubling.

However, something happened that significantly changed my perspective. I was referred to an orthopedic surgeon, and we quickly developed a rapport. By the end of our first session I felt I could trust this person and to do what so many times I have encouraged my own clients to do, take a leap of faith.

Over the years of working with eating disordered clients, I have come to understand the importance of establishing rapport and trust. Yet, it wasn’t until my own experience that I fully appreciated the power of a therapeutic alliance.

The Importance of the Therapeutic Alliance

A collaborative relationship, or therapeutic alliance, between the client and all members of the eating disorders treatment team is essential in order for the patient to move forward in recovery. In the client-dietitian relationship, a therapeutic alliance supports the client with behavioral change and enables her to express emotions, describe behavior, and explore irrational thoughts related to food and eating. The patient can engage in nutritional counseling without fear of being judged or ridiculed.

Strategies for Developing a Therapeutic Alliance

My recent health dilemma prompted me to look at my own clinical practice. I was curious to identify the strategies that I use to develop a therapeutic alliance with clients. I realized my approach is a compilation of lessons learned from colleagues and my experiences with patients.

Establish Boundaries with Patients

Compared to some other team members, the dietitian may have greater difficulty establishing a therapeutic alliance with patients. Clients are typically very aware that the dietitian deals concretely with their symptoms, namely, their eating behaviors and low body weight. Often, clients begin nutritional counseling with assumptions about the dietitian’s intentions. These preconceived ideas can tap into some of the patient’s worst fears, making a trusting relationship elusive.

When I meet a client for the first time, I explore the possibility that the patient has misconceptions about my role. I ask the client how she felt about coming to the nutrition session, and whether she has seen a dietitian or any other “nutrition specialist” in the past. If she has already had nutritional counseling, I try to understand what that experience was like for her. Clients who have had bad experiences need an opportunity to discuss what went wrong and how their time with me can be different.

At this point, I also talk with clients about my role and responsibilities as a dietitian. I let them know that I am the team member responsible for conducting a nutritional assessment and designing a care plan according to their specific nutritional and educational needs. While I gather medical information such as physical signs and symptoms of the eating disorder, I don’t provide medical advice. I also inform clients that I don’t conduct therapy during the nutrition sessions because I have not received the necessary training and certification in psychotherapy. I tell clients in advance that I will direct them to the most appropriate team member when medical or psychotherapy issues arise.

I define my professional boundaries in more detail by telling clients that expressing emotions about food and eating and discussing the meaning behind their eating disorder symptoms is appropriate during nutrition sessions, even though a thorough exploration of the latter is done with the patient’s therapist.

Identify Limits of Confidentiality

Communicating with other team members (e.g., therapist, physician, social worker) is another of the dietitian’s responsibilities. During the initial nutrition session, I identify the team members who will be privy to the information the client shares with me. Dietitians in private practice will need to have clients sign “Release of Information” documents in order to communicate with other health care providers. It is important that clients understand that the dietitian’s contact with other team members increases their chances of receiving comprehensive treatment.

Dietitians who work with children and adolescents will need to identify the family members who will participate with the client in nutrition sessions. The family’s involvement needs to be well defined for the patient before nutrition counseling gets underway.

Clarify the Client’s Expectations of the Dietitian

In the early stages of nutritional counseling, clients need to hear how the dietitian will work with them. Explaining to patients what they can expect may help them feel more at ease.

At a conference in 1998, I heard Leah Graves, RD, LD, dietitian at the Laureate Eating Disorders Program, Tulsa, describe how she develops trust with patients. Leah’s approach emphasizes honesty and integrity with clients. She tells her patients that she will not keep secrets from them and will be honest if miscalculations or errors occur. She explains her role to clients by stating she will not do things to them. Instead, she will take the journey [toward recovery] with them in helping them accomplish their goals.

On numerous occasions, I have seen both rapport and trust enhanced when I have helped the client set goals based on her ability to change. Accomplishing realistic and self-articulated goals empowers patients to continue making changes with greater confidence. But, at the same time, I am clear about the goals I will not support (e.g., weight loss and/or medical instability). I let my clients know that, under these circumstances, they may not be involved in deciding how their treatment progresses. I inform clients that my nutritional counseling philosophy emphasizes personal health and overall quality of life. The focus is not on weight, although it will be monitored as an indicator of nutritional health.

Express Your Beliefs About the Client’s Dilemma

So often patients presenting for treatment are embarrassed about their eating disorder behaviors and ambivalent about their ability to make changes. I believe it is important to let clients know that you will not pass judgment on any information they disclose. I tell clients that I understand and respect the function the eating disorder has served in their life—it has kept them alive.

A few years ago I heard Tami Lyon, MPH, RD, CDE, currently a dietitian in private practice in San Francisco and previous author of “Nutrition Notes,” speak at an international eating disorders conference. She shared a message that she uses with clients in her practice: “I realize that at some point in your life you were distressed and needed to cope. An eating disorder helped by providing you with a set of tools that worked, but it didn’t tell you that using these tools would be so costly in the long run. I would like to work with you in slowly replacing these tools with new ones. Together, we can fill a new toolbox with tools that will enhance the quality of your life, not take away from it.” Tami’s message communicates how she views the clients’ dilemma, and articulates, in a non-intimidating manner, her role in their treatment.

The client may believe that the dietitian has expectations about the client’s recovery (e.g., that it will take a certain amount of time or it will look a particular way). An open discussion can help the dietitian identify these beliefs along with the client’s own expectations about recovery. I let patients know that I see recovery as a process, not an event. Eating behavior changes take time, energy, and a commitment on behalf of the client and the dietitian.

Demonstrate an Interest in the Client’s Life

As a health care provider, I feel it is crucial that I see my client as a person, and not simply as a patient with an eating disorder. Early in the relationship I try to connect with the client and to discuss an aspect of her life that is unrelated to her eating disorder. Mindful of personal and professional boundaries, I try to get to know the client in at least one of these areas: pets, hobbies, school, or vocation. I believe that touching on these topics throughout future nutrition sessions can strengthen the therapeutic alliance between client and dietitian.

— Linda M. Watts, MA, RD