- 1 Introduction
- 2 Background
- 3 Components of a Therapeutic Alliance
- 4 Patient-Centred Care
- 5 Effect on Patient Outcomes
- 6 Measuring the therapeutic alliance
- 7 References
The therapeutic alliance (also referred to as the working alliance) is a description of the interaction between the physiotherapist and their patients. The therapeutic alliance is considered an important aspect of the therapeutic process and can have an impact on treatment outcomes. By establishing a therapeutic alliance, the therapist then seeks to provide patient-centered care, in which the therapist is seen as a facilitator for the patient to achieve their goals, rather than an authority figure. Previous research has highlighted the importance of providing patient-centered care not only in physiotherapy, but other medical professions as well. This is accomplished by encouraging the patient to become more active in their treatment to engage them in a collaborative, active approach to recovery. By establishing a strong therapeutic alliance and encouraging patient participation, therapists can also seek to address psychosocial aspects of pain,  which are often overlooked in traditional unidirectional patient-therapist interactions. This is especially important as recent research supports that the physical treatment alone cannot fully account for the improvement of patient outcomes. 
The therapeutic alliance was first described by Freud in 1912, in which he outlined the concepts of transference and countertransference, which are the unconscious feelings or emotions that a patient feels towards their therapist, and vice-versa.  Further research by Rogers (1951) was the first to highlight empathy as a core characteristic of this therapeutic alliance and Anderson (1962) conceptualized both empathy and rapport as qualities within the “therapeutic bond”.  Hougaard (1994) consolidated previous data into a conceptual structure composed of two branches, the personal relationship area and the collaborative area. The personal relationship area focuses on the socio-emotional aspect of the therapist-patient relationship, while the collaborative relationship area consists of more task-related aspects, such as goal-setting and treatment planning. It was Martin, Garske and Davis (2000) concretely described the therapeutic alliance as “…the collaborative and affective bond between therapist and patient – is an essential element of the therapeutic process.” 
Components of a Therapeutic Alliance
Bordin describes the 3 components that contribute to a strong therapeutic alliance are
- Agreement on goals (Collaborative Goal Setting)
- Agreement on interventions (Shared Decision Making)
- Effective bond between patient and therapist (The Therapeutic Relationship)
Collaborative Goal Setting
Goal setting serves a fundamental role in guiding rehabilitation so that a specific outcome is reached. Setting SMART (Specific, Measurable, Attainable, Relevant and Time Limited) goals is a useful way to ensure goals are successful.
The agreement of goals between the patient and the therapist increases adherence to those goals which in turn leads to improved outcomes. It improves patient satisfaction as well as motivation. All of these factors positively influence the therapeutic alliance. When patients are excluded from this process and goals are simply set for them, it creates a situation of dissatisfaction which will negatively influence the therapeutic alliance
A process for shared decision making is outlined by Elwyn et al whereby you move through a 3 step approach
- Choice Talk
- Step back
- Offer Choice
- Justify Choice- consider preferences
- Check Reaction
- Defer Closure
- Option Talk
- Check knowledge
- List Options
- Describe Options - explore preferences
- Harms and Benefits
- Provide patient decision support
- Decision Talk
- Focus on preferences
- Elicit preferences
- Move to a decision
- Offer review
The Therapeutic Relationship
The therapeutic relationship refers to the professional bond between the therapist and patient. It is the key component of a strong therapeutic alliance.
The following components contribute to the development of a strong therapeutic relationship 
- Communication Skill
- Active listening
- Non-Verbal communication
- Practical Skills
- Patient education that is simple and clear
- Therapist expertise and training
- Patient-Centred Care
- Individualised treatments
- Taking patients opinions and preferences into consideration
- Organisational and Environmental Factors
- Giving patients enough time for thorough assessment and management
- Flexibility with patient appointments and care
Good communicative skills are an integral tool to achieving a strong therapeutic alliance and research has shown that effective communication also leads to increased patient adherence and satisfaction.  Mead and Bower (2000)  identified five key dimensions of patient-centered care which have been associated with a positive therapeutic alliance: 
Several conditions treated by physical therapists appear to have little relation to structural or physiological changes, which can themselves be interpreted with high variability.    Thus, an approach that considers not only biological, but also psychological and sociological factors as well, is needed to appreciate the full scope of the problems presented and provide patient-centered care. 
2. The ‘patient-as-person':
Although the biopsychosocial model seeks to address all of the factors surrounding the patient, it may not be sufficient to fully appreciate the patient experience.  We need to understand that each patient may perceive the same pain experience differently and that eliciting the individual patient’s fears, expectations and feelings of illness should be one of our primary concerns 
3. Sharing power and responsibility:
The patient-practitioner relationship has always been fundamentally seen as a ‘paternalistic’ relationship, which some see as an inevitability due to the competence gap between them.  By shifting patients from ‘consumers’ to active ‘participants’, we can help place patients in control of their own illness, and this has been correlated with better health outcomes. 
4. The therapeutic alliance:
Just as patient-centered care can strengthen the therapeutic alliance, the reciprocal relationship can also occur. As mentioned above Bordin (1979) described the three main components of the therapeutic alliance as 1) agreement on goals, 2) agreement on interventions, 3) effective bond between patient and therapist. 
5. The ‘doctor-as-person’:
Since both the therapeutic alliance and patient-centered care acknowledge the relationship between both therapist and patient, it is thus logical to also place importance of the qualities of the therapist. The interaction between therapist and patient is constant, and the subjectivity of the therapist is something that cannot be separated from this interaction. 
Effect on Patient Outcomes
The therapeutic alliance has previously been shown to improve patient outcomes in both medicine as well as psychology.     It is only recently that investigation has been made into its effects in other rehabilitative sciences. Burns and Evon (2007) studied its effect in cardiac rehabilitation and found that increased self-efficacy is not enough of a factor to predict increase cardiorespiratory fitness, weight reduction and return to work.  Instead, it must be combined with a strong therapeutic alliance to achieve these outcomes, and a poor therapeutic alliance can undermine the potential for improvement. Ferreira and colleagues (2012) examined the relationship between therapeutic alliance and patient outcomes on rehabilitation of patients with chronic low back pain.  They found that a strong therapeutic alliance leads to increased perceived changes following a variety of conservative treatments. Interestingly, a strong therapeutic alliance was associated with improved disability and function outcome measures, but not pain. Fuentes et al (2013) also conducted a study utilizing patients with low back pain, this time measuring the therapeutic alliance’s effect on pain intensity and muscle pain sensitivity.  The results showed that a strong therapeutic alliance can significantly modify perceived pain intensity after IFC treatments, which are displayed below. Another point of interest is the active IFC with limited therapeutic alliance was not statistically different than a sham IFC with a strong therapeutic alliance.
A systematic review of the impact of the therapeutic alliance in physiotherapy for chronic musculoskeletal pain found that a significant impact of the therapeutic alliance on patient outcomes. It recommends communication training in healthcare professionals as a way of improving the therapeutic alliance as well as encouraging patient-therapist collaboration in treatment decisions.
Measuring the therapeutic alliance
Popular outcome measures for the therapeutic alliance include the Working Alliance Theory of Change Inventory, which itself is derived from the Working Alliance Inventory.  Hall et al (2011) found that there was some room for improvement in the WATOCI, specifically relating to the wording in certain sections.  The nine items that remained were found to be a uni-dimensional tool for measuring the therapeutic alliance, despite demonstrating a ceiling effect. Due to the complexity of the therapeutic alliance it may be difficult to find a perfect measurement, however patient-administered outcomes are a step in the right direction as patient perception of the therapeutic alliance has been found to be a better predictor of outcome than therapist perception. 
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