The importance of therapeutic alliance

Physiotherapy has long focused on identifying specific treatment interventions for patients in the hopes of maximizing clinical outcomes. Despite our best efforts, specific treatments often demonstrate modest improvements when compared with competing interventions. This lack of consistent results has led to therapists developing complex treatment models in an attempt to make our clinical world make sense.  

Could it be that we have been looking in the wrong direction for far too long and need to make a paradigm shift where the process by which we interact and deliver our healthcare interventions is as important as the intervention itself? Are some of the significant treatment effects seen clinically the result of the therapist and patient relationship, rather than just a specific treatment intervention?

There is emerging evidence that a significant component of clinical outcomes is shaped by the therapeutic alliance (TA) established between patient and therapist. How do we go about maximizing these effects?

TA is defined as the collaborative and affective bond, or the positive social relationship between the physiotherapist and the patient. It’s believed that there are many aspects that contribute to the establishment of a therapeutic working relationship that include active listening, nonverbal behaviors, demonstration of empathy, respect and collaboration.

Accelerated Motion Physiotherapy

Although the research into this area is still limited with respect to physiotherapy, the results are promising. In one interesting study, patients with low back pain were randomized to one of four groups: standard encounter with IFC, enhanced therapeutic alliance with IFC, standard encounter with sham IFC, and enhanced therapeutic alliance with sham IFC with short-term pain relief as the outcome of choice.

As you might guess, those patients who received the enhanced therapeutic alliance (which simply consisted of listening to the patient and the story behind their pain), had greater pain relief than those who received the standard encounter. Now, the argument could be made that these were only short-term changes in pain, but what about the big picture? Fuentes et al. recently published a trial exploring the relationship between therapeutic alliance and outcome for patients with persistent low back pain. At visit two, a higher therapeutic alliance predicted better outcomes for pain, disability and function at eight-week follow-ups, and the effect size was not small.  Those who scored high on therapeutic alliance rating could expect a 20% improvement on their disability outcome scores compared to those with a low therapeutic alliance rating.

If these changes are not enough to convince you that it is worthwhile to foster a therapeutic alliance, consider some of the other benefits that come with a high therapeutic alliance. Patient’s satisfaction with physiotherapy treatment is generally based on their relationship with the clinician, not the clinical outcome. Heck, patients sue their physicians typically because of a fractured relationship with the clinician, not based on the clinical outcome. Finally, there is evidence that clinicians find their interactions with patients more satisfying when there is a higher level of therapeutic alliance.

One long held belief is that bedside manner is an innate quality that only some clinicians are born with. Although some individuals may be predisposed to having higher abilities to form a therapeutic relationship with their patients, there is good evidence that clinicians can be trained to improve their skills in this area. In one study, physicians were randomly assigned to either serve as a control group or provided with three hours of training that focused on improving awareness of the neurobiology of empathy, communication strategies and the ability to decode facial expressions. Not surprisingly, at one month follow-ups, those receiving the empathy training intervention demonstrated significantly improved empathy scores from their patients.

Curtis Tait, Accelerated Motion Physiotherapy

So what are some simple things that you can do to start improving therapeutic alliance? Here are three easy things to get you started:

  1. Shut up! Well maybe I’m being a little harsh and not achieving therapeutic alliance with the reader……  But every patient has a story to tell and it is imperative that they are heard and validated. I start most of my first assessments with the words, “so, tell me your story,” then I put my computer off to the side, lean in and listen. In a classic study, when observed, physicians only allowed their patients to complete their solicited reason for the visit without interrupting about 25% of the time, and the average time until the physician interrupted their patient was 18 seconds. Interestingly, no patient spoke for longer than 150 seconds if allowed to complete their opening statement, and they would often leave psychosocial components of their history to the end of their discussion. Based on our evolving understanding of pain sciences and its relationship to the psychosocial, I’d suggest that great value can be placed on not interrupting the patient and listening for an extra 132 seconds on their first visit!

  2. Ask patients what they are hoping to get from the clinical visit. Not meeting a patient’s expectations, or naively believing that they simply want what you are trained to provide, is often a recipe for disaster. Patient dissatisfaction occurs when their expectations are not met, irrespective of how reasonable those expectations may be. If we know what patients are expecting, we have an opportunity to help shape expectations and provide the exact service they are looking for.

  3. Practice shared decision making with your patients; this is the act of the clinician and the patient making a decision regarding treatment together, based on the best available evidence. After an assessment, summarize your findings and then give your patient potential treatment options with the possible costs and benefits of the interventions. Shared decision making does a few key things to help improve the clinical process; it increases patient self-efficacy as they actively participate in decision-making regarding their care.

Accelerated Motion Physiotherapy

Interestingly, shared decision making may also help more patients utilize physiotherapy than other more costly and invasive interventions. There is evidence that patients choose more conservative treatments when given the opportunity to participate in shared decision making.

This is by no means an exhaustive list, and the application of soft skills needs to be modified and altered appropriately with each individual patient. I would argue that the true “Art” of physiotherapy is not the ability to poke a patient with a needle, manipulate a joint or teach a fancy exercise, but rather the skillful interpersonal communication skills required to establish therapeutic alliance with our patients. It is time to get away from being enamored with just interventions and looking for that magic bullet treatment that will serve as a panacea. Regularly reflecting on our communication skills, and spending time learning how we can foster therapeutic alliance, is well worth the effort both from an outcome-based perspective and personal satisfaction as clinicians. A great place to start is with the timeless paper the four habits model.