In physical therapy, listening and developing a strong therapeutic alliance goes a long way.
As a physical therapist, every plan of care starts with the initial evaluation. While the follow up treatments are important for applying the appropriate interventions including exercise, mobility, and manual therapy, the initial evaluation remains the cornerstone of our care.
A well done initial evaluation provides us with valuable data. We get a subjective history regarding the patient’s pain or injury. We establish a baseline of impairments by performing a thorough physical examination including special tests, strength, and mobility. Then, based on the patient’s history and presentation, we educate our patients on activity modifications and exercises to be performed at home. However, the most important part of this first visit is creating a strong therapist and patient relationship that will build a solid therapeutic alliance.
What is a therapeutic alliance?
A therapeutic alliance is a positive relationship that is developed between the therapist and patient. It is built on respect, empathy, communication, and collaboration1. Essentially, demonstrating warmth, active listening, and tailoring your interactions to your patient can help build a positive therapeutic alliance.
How do we develop a therapeutic alliance?
Developing a quality therapeutic alliance starts with the initial evaluation. As mentioned earlier, one of the first things we do is get a history. We have been taught as therapists to ask open ended questions. We have also been taught to enquire about the quality of the pain, what specific movements make it better or worse, is there numbness or tingling associated with the pain, and if there are any medications being utilized to manage the symptoms. However, if we just listen, the patient will tell us everything we need to know.
According to one study, in the United States a patient only talks for 22 seconds prior to being interrupted by the examining physician. This same study indicates that if the patient would be allowed to speak without being interrupted, most patients finish their subjective history on their own in under 2 minutes2. By allowing the patient to speak uninterrupted, they will answer many of the questions that we have, without prompting. In doing so, we start to build a patient centered therapeutic alliance as we can demonstrate respect and patient centered communication in just the first few moments of our interactions. Listening goes a long way.
Collaboration in therapy is also a way to develop a strong therapeutic alliance. The best way to collaborate with the patient in front of you is to allow them to be part of the decision making process. When building your goals for physical therapy, we must go beyond the strength and range of motion goals. It is imperative we link the objective impairments to the person we see in front of us. We must allow the patient to be part of the goal making process. By determining why they are in physical therapy and then linking their goals to the interventions, progress can be so much more meaningful for both the patient and the therapist.
Furthermore, seeking patient feedback can be helpful in developing a strong therapeutic alliance. Patients may not always feel comfortable asking questions, letting you know how certain things feel, or if they feel they are responding to treatment. Directly asking them how they feel therapy is going can initiate conversations that improve the efficiency and effectiveness of therapy. By demonstrating that you genuinely care about their experience in therapy, the patients will feel much more comfortable providing immediate feedback, thus allowing for improvements in care.
Studies show better therapeutic alliances can lead to positive health outcomes in psychology and medicine. In physical therapy, studies have also noted improved outcomes associated with disability and function, though not pain3. This indicates, while no specific change in pain was made, the patient noted improvements in their disability and function. Providing an environment that fosters a strong therapeutic alliance will also make it easier for the patient to “buy in” on the various therapeutic interventions we apply in physical therapy leading to better outcomes.
In summary, a strong therapeutic alliance can be beneficial in developing a positive relationship with our patients. By using appropriate communication and listening during the evaluation, collaborating during goal setting, and responding to patient feedback a therapeutic alliance can be built fostering better patient experience.
- Babatunde, F., MacDermid, J. & MacIntyre, N. Characteristics of therapeutic alliance in musculoskeletal physiotherapy and occupational therapy practice: a scoping review of the literature. BMC Health Serv Res 17, 375 (2017). https://doi.org/10.1186/s12913-017-2311-3
- Langewitz W, Denz M, Keller A, Kiss A, Rüttimann S, Wössmer B. Spontaneous talking time at start of consultation in outpatient clinic: cohort study. BMJ. 2002 Sep 28;325(7366):682-3. doi: 10.1136/bmj.325.7366.682. PMID: 12351359; PMCID: PMC126654.
- 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
Written By: Thomas Dyke, PT, DPT, OCS