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The Therapeutic Alliance: An Exploration of an Under-rated Healing Agent

I can’t quite wrap my head around this:

In a study looking at communication with patients with cancer, 90% of 384 empathic opportunities were ignored by physicians when treating these patients.1 Certainly in a time of fear, uncertainty and horror at a possibly terminal diagnosis, patients need empathy from their caregivers just as much as life-saving treatment? 

I’m trying to understand why this empathy is such an elusive trait in the clinical encounter. Is it that physicians have little time and are too busy to empathize? Is it because they are not trained in such a skill? Is it that they are trying to distance themselves from the patient situation because it is too emotionally difficult, sort of like a self-preservation technique? Whatever the reason, there is slim chance of building a therapeutic alliance (TA) with their patients without empathy. Without a healthy TA, we cannot provide genuine person-centered care (PCC). In fact, a weak therapeutic relationship is considered to be low value care.2

A component of patient-centered care

The TA is one of the more recognised of the 6 components of PCC according to Langberg et al.,3 which I discuss extensively in my blog here. Its importance to healthcare is exemplified by the fact that the TA is an “environmental factor” in the International Classification of Functioning, Disability and Health model.4

Otherwise known as the patient-provider relationship, the therapeutic relationship, rapport, and the working or helping alliance, the TA is considered a contextual factor that can moderate or mediate the effects of an intervention.5,6 It creates a relational “climate” for engagement between the patient and provider that can give meaning to the patient, impact outcomes and enhance mutuality.7 Fuentes et al8 actually consider the TA a therapeutic agent.

Therapeutic alliance between a patient and her healthcare provider

Can we please have a definition?

The concept of the TA originated from Freud’s 1912 theory of transference, and much of what we know about the TA is from the psychology literature. In 1970 Bordin9 (from the psychology literature) proposed a tripartite model of the TA in an effort to define what it entails:

  1. Therapist-patient agreement on goals of treatment
  2. Therapist-patient agreement on interventions
  3. Affective bond between patient and therapist (reciprocal positive feelings)

The TA is a very latent construct, and as with the definitions of PCC and shared decision-making (which I blogged about previously here), there is no clear conceptualization. It is a vague and complex concept, and it is precisely this issue that limits the interpretation of the research on the topic.10,11

However, based on the current research, it seems to boil down to the presence of trust, empathy, positive regard, and a warm, non-judgemental, positive social relationship that allow for concordance between patient and provider throughout the therapeutic process.8,12–15

I think that the best conceptualization of the TA can be created through qualitative studies where we actually “see” it through the patients’ and health providers’ own words and experiences. Some of my favourite quotes that illustrate the concepts of the TA, taken form qualitative studies, are:

“If you give out the impression that you know what’s happening in this person’s back without showing them the interest or without making an effort in understanding it, you won’t be able to help them. The physiotherapist is not only dedicated to understanding the patient’s physical situation, but also ‘a picture of the unspoken’” (a physical therapist from Miciak et al16)

“They were busy as can be, just on a cycle going from one to the next to the next and coming back. They always took the time to make you feel like you were a decent person” (a patient from Miciak et al16)

“The closeness, gentleness, just being there is important, as you have to go through certain moments that are unpleasant.” (patient from Morera-Blaaguer at al17)

“It is our challenge and duty to connect with everyone.” (physical therapist from Miciak et al4)

“I want to reduce the . . . if there’s an impression of status or power from the patient’s point of view . . . I think it’s my technique of illustrating to them without words of course that I’m no better or worse than them. I’m not here to chastise. I’m not a power figure above them…” (physical therapist from Miciak et al4)

“For me, every condition that a person comes in with is not repetitious. For you [patient] that is a new condition. I might have seen thousands of backs by now but your back problem is your back problem. If I do not show the interest or the excitement in working with you, it doesn’t make a difference how many backs I have seen.” (PT form Miciak et al4)

“She explains to me what she’s doing and why she’s doing it, what I should feel from it, what I should get out of it and where it should go.” (patient from Miciak et al4

“I think knowing that you have someone that cares about your condition is great.” (patient from Bunzli et al13)

What influences the therapeutic alliance?

There are a number of factors that influence the development or the rupture of the TA that appear consistently across a number of studies.10,11,18 These include:

  1. Patient expectations. Patients may come into the care process with unrealistic expectations. If not addressed, it could have a negative impact on the TA.
  2. Personalized/individualized treatment. This includes care that is focused on the patient as a person, which is one of the categories of patient-centered care. Personalized treatment encompasses holistic care where the patient is understood in the context of their life experience. It encourages the health provider to focus on how things are done, rather than what is done, which can enhance the quality of the healthcare process.
  3. Partnership. This involves a team approach between patient and provider, a sense of mutuality between the two. In this relational space there is respect, knowledge exchange, the balance of power, and shared decision-making (another component of PCC)
  4. Roles and responsibilities of the health provider. These include motivating and educating the patient in a professional manner, as well as activating the patient’s resources to help the patient gain control of their condition. This fosters independence and self-management.
  5. Congruence. Both the health provider and patient must be on the same page regarding problem identification, treatment and goals. This reflects Bordin’s9 first 2 aspects of his definition of the TA.
  6. Communication. This refers to both verbal and non-verbal skills. It also includes active listening and the use of visual aids. As a patient from Bunzli et al11 states, “I found myself questioning it a couple of times….But I think that you just have to have that communication, that comfortable atmosphere has to be there.”
  7. Relational aspects. This is a collective term for traits like empathy, caring, warmth and faith in the patient. This seems to be defined from the therapist’s perspective.
  8. Besely et al15 defines this last element as influencing factors. These include:
    1. External factors such as the structure, process and environment of the care experience. This can be anything from waiting time, to direct access to the health provider, to flexibility of the provider and the organisation as well as the time spent with the patient, and the ambiance of the clinic or hospital.
    2. Provider pre-requisites. These refer to the skills and competence of the provider, the provision of appropriate explanations to the patient, the life experiences and personal characteristics of the provider. This is reflective of the doctor-as-person component of the PCC definition.
    3. Patient pre-requisites. These encompass the patient characteristics, their resources and life experiences as well as their willingness to engage.

It’s important to note here that both the patient and health provider are responsible for contributing to the TA. Patient behaviours such as anger and hostility can understandably have a negative impact the TA.12 However, it is easy for the provider to blame a “difficult” patient for a poor TA, when often times, the provider has not worked to create a suitable enough relational climate for the patient to engage fully in the healthcare process. While I wholeheartedly acknowledge that there are patients with extremely challenging personalities, who are so difficult to work with that we must take a deep breath before we greet them in the waiting room, I think that a lot of providers are too quick to brush off such patients as those they cannot help.

A weak TA can result from the absence or a deficit in any of the above factors. A lack of empathy on the part of the provider; the inability or refusal to recognise or acknowledge a potential rupture in the TA; inappropriate verbal and non-verbal responses such as changing a topic when a situation is difficult – these are all ways that a health provider can increase tension in the relationship and negatively affect the TA.19 Provider styles that are confrontational, critical, blaming or “bossy,” and even inflexible, also have a negative impact.5  Of course there are many more ways that this can be done, and I’m sure we’ve all had some stomach-churning experiences that we can recall to add to this list.

The therapeutic alliance and outcomes

For all the bruhaha about the TA, you may be surprised to learn that the study of the TA in physical therapy is in its infancy.11,16,20 The earliest studies, according to Babatunde et al10 in physical therapy are from 1981, with an increase in publications between 2011 and 2016. In my research I have noticed a flurry of publications within the last 3 years.

In the psychology literature, where the TA has been heavily studied, the TA had a moderate positive relationship with outcomes, and results have been consistent among studies.5 On the other hand, the research in the physical therapy literature has shown mixed results regarding the effects of the TA on outcomes, but with a tendency towards more positive outcomes.

Despite the relatively small number of studies on the TA in rehabilitation, there sure have been a relatively large number of systematic reviews! In 2010, a systematic review by Hall et al21 found a positive relationship between the TA and pain, disability, mental health and patient satisfaction. Another systematic review, this time by Taccolini Manzoni et al,20 challenged Hall’s results regarding pain as they found a lack of good literature investigating the relationship of the TA to pain-related outcomes. Yet another review in 202012, which is the most recent one that I’ve come across, reported that there is not much evidence in support of the TA because of the poor quality of the studies.

However, despite this high level of bias in the reviewed studies, the authors still determined that a strong TA may be more effective than traditional physical therapy in addressing pain. They made special mention of a particularly strong, yet pleasantly simple, study by Fuentes et al.8 These researchers compared the effects of enhanced vs limited TA on muscle pain sensitivity and pain intensity in patients with chronic low back pain (CLBP) receiving either sham or active interferential current (ICF). In this study, the authors placed their patients into 4 groups:

Group 1: Limited TA with active IFC

Group 2: Limited TA with sham IFC

Group 3: Enhanced TA with active IFC

Group 4: Enhanced TA with sham IFC

The authors found that the best results were obtained in group 4, which had the active IFC together with the enhanced TA. The smallest effect was seen in group 2 with the limited TA and the sham IFC. The authors were actually surprised at the large improvement in group 4, which exceeded the clinically meaningful difference for the pain intensity and muscle pain sensitivity outcomes. The study had some limitations, the most poignant of which is that the authors tested the immediate effect of the TA only. We therefore cannot make decisions about the long-term effects. Nevertheless, the results are certainly encouraging, especially since patients want immediate relief when they see us in clinic!

Other studies have shown that the TA is a large contributor to patient satisfaction.22 This intuitively makes a lot of sense. If you get along well with your healthcare provider, and work as a team towards common goals, then it follows that you should be a relatively content patient, even if the outcomes are not exactly as hoped.

The challenges in rehabilitation

While the studies in physical therapy suggest some positive influence of the TA on outcomes, they are wrought with challenges, making interpretation a bit of a rocky road. The primary challenge is that we still do not have a clear conceptualization of what the TA really is. This makes measurement really difficult. There is heterogeneity of measurement tools used, and they measure different aspects of the TA. It’s therefore quite challenging difficult to come to a definitive decision about the TA’s influence on outcomes. 

Furthermore, most of the measurement tools are taken from psychology, and do not transfer perfectly to rehabilitation. No tools have been validated in physical therapy, at least up to 2017,10 and I have not seen any validation studies since. Most tools that measure the TA have also been implemented from the provider’s perspective, so we may be missing important aspects from the patient’s point of view.

Hands and heart showing therapeutic alliance

Exactly how does the therapeutic alliance work?

So just how does the TA work?  What mechanisms are involved that allow it to exert its effect on outcomes? These questions have been explored in some studies.6,10,23 While the answer to these questions is still unclear, there have been a few suggestions.

The TA may exert its influence through several mediators and moderators. A mediating variable is one that changes during treatment, and the change in these mediating variables influences the outcome of the intervention. Better adherence to treatment, prioritization of goals, improved autonomy and motivation have been cited as mediators in the literature.10,23 Again, this makes intuitive sense. Maybe the reason we love motivated patients who are adherent to the rehab process, is that they usually get better? 😀

Unsgaard-Tondel and Soderstrom6 offer the self-determination theory as a mediator between the TA and positive outcomes. This theory suggests that people are motivated to act or change once three universal psychological needs are met. These needs are competence, relatedness (or connection), and autonomy. Once these are fulfilled, the person becomes intrinsically motivated to act. The theory also states that it is important that the patient experiences this motivation as “self-determined,” hence the name. The TA is the context that encourages this change in the patient, as it creates an environment of security and relatedness, which enables the patient to “buy in” and follow the treatment, which should enhance the outcomes.

A moderating variable is one that is a baseline characteristic that interacts with treatment to influence the direction and magnitude of the outcome. That said, age has been shown to be a moderator between the TA and adherence to treatment. Younger and more autonomous individuals tend to have better adherence than older individuals.10 Other studies have also suggested that differences in culture, gender and race can affect the relationship between the patient and provider.24–27 Unfortunately it is not uncommon for studies to find that physicians often underestimate the pain of persons from ethnic groups different to themselves.28

I can think of no better example than the ethnography by Anne Fadiman, titled “The Spirit Catches you and you Fall Down.” It’s the story of how Western ethnocentricity harmed the care of a Hmong child who was epileptic, and the family’s challenge with the healthcare system. Even though Western doctors were doing their best to help, they lacked the skill and resources to communicate effectively with the family. It’s my favourite book. I highly recommend the read! 🤓

Wrap up

So, as we end the discussion of this second component of person-centered care, we see a theme starting to emerge – we don’t have a clear conceptualization of any of the concepts so far. We remain uncertain about PCC, and about shared decision-making, and now the TA as well. It is precisely this that makes it difficult to research and come to definitive conclusions. However, while the research leaves questions to be considered, intuition is rather definitive…if you were a patient, wouldn’t you want a good relationship with your health provider?

Stay tuned as we continue the series on the components of PCC in the upcoming monthly blogs. Be sure to subscribe so you don’t miss a beat!

As ever, I’d love to hear your comments. You can either write them below or connect with me on the socials, which you can find in the side bar. Feel free to share the article as well as I’d love to get more discussion going on person-centered care!

References:

 

  1. Morse DS, Edwardsen EA, Gordon HS. Missed Opportunities for Interval Empathy in Lung Cancer Communication. Arch Intern Med. 2008;168(17):1853. doi:10.1001/archinte.168.17.1853
  2. Zadro JR, Maher CG. Overview of the Drivers of Low-Value Care Comment on “Key Factors that Promote Low-Value Care: Views of Experts From the United States, Canada, and the Netherlands.” Int J Health Policy Manag. Published online February 14, 2022:1. doi:10.34172/ijhpm.2022.6833
  3. Langberg EM, Dyhr L, Davidsen AS. Development of the concept of patient-centredness – A systematic review. Patient Educ Couns. 2019;102(7):1228-1236. doi:10.1016/j.pec.2019.02.023
  4. Miciak M, Mayan M, Brown C, Joyce AS, Gross DP. A framework for establishing connections in physiotherapy practice. Physiother Theory Pract. 2019;35(1):40-56. doi:10.1080/09593985.2018.1434707
  5. Vowles KE, Thompson M. The Patient-Provider Relationship in Chronic Pain. Curr Pain Headache Rep. 2012;16(2):133-138. doi:10.1007/s11916-012-0244-4
  6. Unsgaard-Tøndel M, Søderstrøm S. Therapeutic Alliance: Patients’ Expectations Before and Experiences After Physical Therapy for Low Back Pain—A Qualitative Study With 6-Month Follow-Up. Phys Ther. 2021;101(11):pzab187. doi:10.1093/ptj/pzab187
  7. Step MM, Rose JH, Albert JM, Cheruvu VK, Siminoff LA. Modeling patient-centered communication: Oncologist relational communication and patient communication involvement in breast cancer adjuvant therapy decision-making. Patient Educ Couns. 2009;77(3):369-378. doi:10.1016/j.pec.2009.09.010
  8. Fuentes J, Armijo-Olivo S, Funabashi M, et al. Enhanced Therapeutic Alliance Modulates Pain Intensity and Muscle Pain Sensitivity in Patients With Chronic Low Back Pain: An Experimental Controlled Study. Phys Ther. 2014;94(4):477-489. doi:https://doi.org/10.2522/ptj.20130118
  9. Bordin ES. The generalizability of the psychoanalytic concept of the working alliance. Psychother Theory Res Pract. 1979;16(3):252-260. doi:10.1037/h0085885
  10. 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;36(8):886-898. doi:10.1080/09593985.2018.1516015
  11. Bunzli S, McEvoy S, Dankaerts W, O’Sullivan P, O’Sullivan K. Patient Perspectives on Participation in Cognitive Functional Therapy for Chronic Low Back Pain. Phys Ther. 2016;96(9):1397-1407. doi:10.2522/ptj.20140570
  12. Wilson S, Chaloner N, Osborn M, Gauntlett-Gilbert J. Psychologically informed physiotherapy for chronic pain: patient experiences of treatment and therapeutic process. Physiotherapy. 2017;103(1):98-105. doi:10.1016/j.physio.2015.11.005
  13. Maxwell C, McCreesh K, Salsberg J, Robinson K. ‘Down to the person, the individual patient themselves’: A qualitative study of treatment decision‐making for shoulder pain. Health Expect. Published online 2022. doi:10.1111/hex.13464
  14. 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. 2017;17(1):375. doi:10.1186/s12913-017-2311-3
  15. Besley J, Kayes NM, McPherson KM. Assessing therapeutic relationships in physiotherapy: literature review. N Z J Physiother. 2011;39(2):81-91. Accessed March 18, 2022. https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=104670427&site=ehost-live
  16. Miciak M, Mayan M, Brown C, Joyce AS, Gross DP. The necessary conditions of engagement for the therapeutic relationship in physiotherapy: an interpretive description study. Arch Physiother. 2018;8:3. doi:10.1186/s40945-018-0044-1
  17. Morera-Balaguer J, Botella-Rico JM, Catalán-Matamoros D, Martínez-Segura OR, Leal-Clavel M, Rodríguez-Nogueira Ó. Patients’ experience regarding therapeutic person-centered relationships in physiotherapy services: A qualitative study. Physiother Theory Pract. 2019;37(1):17-27. doi:10.1080/09593985.2019.1603258
  18. O’Keeffe M, Cullinane P, Hurley J, et al. What Influences Patient-Therapist Interactions in Musculoskeletal Physical Therapy? Qualitative Systematic Review and Meta-Synthesis. Phys Ther. 2016;96(5):14.
  19. Miciak M, Rossettini G. Looking at Both Sides of the Coin: Addressing Rupture of the Therapeutic Relationship in Musculoskeletal Physical Therapy/Physiotherapy. J Orthop Sports Phys Ther. 2022;52(8):500-504. doi:10.2519/jospt.2022.11152
  20. Taccolini Manzoni AC, Bastos de Oliveira NT, Nunes Cabral CM, Aquaroni Ricci N. The role of the therapeutic alliance on pain relief in musculoskeletal rehabilitation: A systematic review. Physiother Theory Pract. 2018;34(12):901-915. doi:10.1080/09593985.2018.1431343
  21. Hall AM, Ferreira PH, Maher CG, Latimer J, Ferreira ML. The Influence of the Therapist-Patient Relationship on Treatment Outcome in Physical Rehabilitation: A Systematic Review. Phys Ther. 2010;90(8):1099-1110. doi:10.2522/ptj.20090245
  22. Hirpa M, Woreta T, Addis H, Kebede S. What matters to patients? A timely question for value-based care. Fong ZV, ed. PLOS ONE. 2020;15(7):e0227845. doi:10.1371/journal.pone.0227845
  23. Alodaibi F, Beneciuk J, Holmes R, Kareha S, Hayes D, Fritz J. The Relationship of the Therapeutic Alliance to Patient Characteristics and Functional Outcome During an Episode of Physical Therapy Care for Patients With Low Back Pain: An Observational Study. Phys Ther. 2021;101(4):pzab026. doi:10.1093/ptj/pzab026
  24. Johnson-Jennings M. Factors Influencing Healthcare Providers’ Chronic Pain Assessment and Treatment Decision-Making among American Indian Populations: Does Racial Concordance or Ethnic Salience Matter? The University of Wisconsin – Madison; 2010. https://ezproxylocal.library.nova.edu/login?url=https://www.proquest.com/dissertations-theses/factors-influencing-healthcare-providers-chronic/docview/860958537/se-2?accountid=6579
  25. Kozlov N, Benzon HT. Role of Gender and Race in Patient-Reported Outcomes and Satisfaction. Anesthesiol Clin. 2020;38(2):417-431. doi:10.1016/j.anclin.2020.01.012
  26. Staton LJ, Panda M, Chen I, et al. When race matters: disagreement in pain perception between patients and their physicians in primary care. J Natl Med Assoc. 2007;99(5):532-538. https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=105993565&site=ehost-live
  27. Earl TR, Saha S, Lombe M, et al. Race, Relationships, and Trust in Providers among Black Patients with HIV/AIDS. Soc Work Res. 2013;37(3):219-226. doi:10.1093/swr/svt017
  28. Johnson-Jennings M, Tarraf W, González HM. The Healing Relationship in Indigenous Patients’ Pain Care: Influences of Racial Concordance and Patient Ethnic Salience on Healthcare Providers’ Pain Assessment. Int J Indig Health. 2015;10(2):33-50. https://ezproxylocal.library.nova.edu/login?url=https://www.proquest.com/scholarly-journals/healing-relationship-indigenous-patients-pain/docview/1787817916/se-2?accountid=6579

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