What is Therapeutic Alliance?

In this day and age, where healthcare providers are busier than ever. It is easy to be overwhelmed by the never ending admin duties that need to get done throughout a long day . However, this leads healthcare providers to make the all too common mistake of ignoring one of the most important factors that influences a patient’s clinical outcomes in outpatient physical rehab services. This factor is known as establishing a therapeutic alliance. Therapeutic alliance is a cooperative, working relationship between the patient and the provider (1). The conditions set in this relationship are mutually negotiable, and focus on several key areas: (1)

• The core conditions of therapeutic change set by the provider

• The patient’s attitude towards the provider

• The provider’s style of relating to the patient

• Mutual goals that have been agreed upon and regularly reviewed

• Tasks that are carried out by both the patient and the provider

I’ll quickly explain the core conditions of therapeutic change and patient attitude.

The Core Conditions of Therapeutic Change (2)

There are three core conditions of treatment, these are empathy, congruence, and unconditional positive regard.

• Empathy: In healthcare, it’s the providers understanding of their patient’s experiences and feelings in an accurate and compassionate way.

• Congruence: Refers to the provider being real, authentic, and genuine with their patients. Their inner experience and outward expression match.

• Unconditional positive regard: This means that the provider genuinely cares for their clients, and does not judge their thoughts, feelings, or behaviors as good or bad.

Patient’s Attitude Towards the Provider (3)

This can be influenced by many factors, however the most important factors are:

• Trust

• Patient experiences

• Patient education background

• Patient health literacy

All of these areas, should be established between the provider and the patient, prior to receiving care, and both parties should regularly build upon this throughout the cycle of care. This is critically important, because it ensures the patient that the provider has their best interest at heart. If this is established, it has the potential to significantly improve patient outcomes (4, 5, 6). If there is doubt in this, this can negatively impact the outcomes of their care (4).

I know when I first started working as a licensed physical therapist, I had trouble navigating trying to balance patient interactions and documentation responsibilities. The hardest part about this was that every day looked different than the previous one. However, the best thing I could’ve done was to reflect on how well I managed my performance each day, and made adjustments accordingly. For patients, I hope this article sheds some light on the expectations you should have for your providers, as far as their responsibilities of forming a partnership with you to address your needs. For providers, I hope this article inspires providers to implement reflecting on how they’ve managed patient relationships as part of their clinical development.

References:

1. American Psychological Association: (https://dictionary.apa.org/therapeutic-alliance)

2. 1. Watson, J. C. (2002). Re-visioning empathy. In D. J. Cain (Ed.), Humanistic psychotherapies: Handbook of research and practice (pp. 445-471). American Psychological Association, Washington, DC.

3. H. Wittink, J. Oosterhaven, Patient education and health literacy, Musculoskeletal Science and Practice, Volume 38, 2018, Pages 120-127, ISSN 2468-7812, https://doi.org/10.1016/j.msksp.2018.06.004.

4. Bolsinger J, Jaeger M, Hoff P, Theodoridou A. Challenges and Opportunities in Building and Maintaining a Good Therapeutic Relationship in Acute Psychiatric Settings: A Narrative Review. Front Psychiatry. 2020;10:965. Published 2020 Jan 15. doi:10.3389/fpsyt.2019.00965

5. Kinney M, Seider J, Beaty AF, Coughlin K, Dyal M, Clewley D. The impact of therapeutic alliance in physical therapy for chronic musculoskeletal pain: A systematic review of the literature. Physiother Theory Pract. 2020 Aug;36(8):886-898. doi: 10.1080/09593985.2018.1516015. Epub 2018 Sep 28. PMID: 30265840.

6. Paulo H. Ferreira, Manuela L. Ferreira, Christopher G. Maher, Kathryn M. Refshauge, Jane Latimer, Roger D. Adams, The Therapeutic Alliance Between Clinicians and Patients Predicts Outcome in Chronic Low Back Pain, Physical Therapy, Volume 93, Issue 4, 1 April 2013, Pages 470–478, https://doi.org/10.2522/ptj.20120137