Enhancing the Therapeutic Alliance for Patients with Chronic Pain
By Dylan Sheedy, SPT
Background
I have always been interested in the nuances of interpersonal communication and their impacts on the development of robust, fulfilling interpersonal relationships. As I began my pursuit of a career in physical therapy I became fascinated by the impact of psychoemotional factors, socioeconomic factors, and individual personal history on the physical manifestation and clinical presentation of pain and pathology. During my time in the clinic I noticed that the patients who got better weren’t necessarily the ones who received cutting edge interventions and elaborate home exercise programs. I noticed that the patients who appeared to enjoy therapy and appeared to like their therapist tended to have better outcomes. Upon finding research to support these observations, I became interested in finding ways to foster a positive therapeutic relationship between patient and provider.
Statement of Need
Chronic musculoskeletal pain poses a significant healthcare burden and is estimated to affect one in five adults worldwide.1 Chronic musculoskeletal pain can be difficult to manage from a purely surgical or medical perspective, and healthcare providers are increasingly utilizing self-management and pain-management techniques in conjunction with traditional medical care.2 Psychologically informed interventions are used to treat patients with chronic pain, but these interventions are more widely practiced by physicians and psychologists.3 Considerations for the quality of the therapeutic relationship between practitioner and provider are gaining traction in the physical therapy literature, and the use of psychologically informed therapy is emerging in clinical practice, but these techniques are not widely used.
Traditional physical therapy education programs dedicate significant portions of their coursework to the identification and mastery of biomechanical and biological contributions to pain. However, recent research indicates that pain experiences are complex and can encompass more than biomechanical factors.4 As such, further exploration into the influence of psychologically informed interventions and a positive therapeutic alliance on pain outcomes is warranted. This capstone project suggests techniques to foster a positive therapeutic alliance and addresses an area for growth in traditional physical therapy education programs.
Purpose
While some individuals are inherently talented communicators, I believe that anyone can construct strong relationships by practicing consistent behaviors and implementing an appropriate mental framework that is centered around self-awareness. The goal of this project is to increase practitioner awareness of the influence that relationship building has on therapeutic outcomes for patients with chronic pain. This project suggests techniques to increase every provider’s ability to facilitate a positive therapeutic relationship.
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Products
This capstone project includes a recorded VoiceThread presentation that covers key components of the therapeutic alliance, provides recommendations for fostering a positive therapeutic alliance, and offers advice to enhance practitioner resilience when managing patients with chronic pain. A Clinical Handout accompanies the VoiceThread presentation and contains recommendations for both appropriate and inappropriate verbal and non-verbal communication behaviors for a beneficial therapeutic alliance. This project was also presented virtually via Zoom (due to COVID-19 social distancing recommendations) for dissemination to current eDPT cohorts and UNC DPT faculty.
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Evaluation
The capstone advisor and capstone committee members provided feedback throughout the development of the presentation and clinical handout. They provided constructive advice on the appropriate scope of the material and the specific content of the capstone products.
Feedback Formswere distributed to audience members after the virtual presentation to gather their perspectives on the breadth and depth of the information, the effectiveness of presentation techniques, and the clinical utility of the content. Feedback will be synthesized and integrated into future iterations of the presentation as appropriate.
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Health Literacy
Current and future healthcare providers are the target audience of this capstone presentation, and the health literacy considerations reflect this specialized audience. The content of the presentation and clinical handout contains language that is specific to physical therapy while remaining clear and concise. The content is intended to be simple and digestible with actionable recommendations for clinical practice.
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Self-Reflection
I am pleased with the final products of this capstone project. I feel my capstone addresses an aspect of patient care that is rarely touched on during traditional eDPT education programs. I am especially proud of the practitioner resilience practices that are promoted in this presentation, and I hope they will help my peers and colleagues experience long, fulfilling careers in physical therapy.
The process of developing this presentation challenged my assumptions and required me to reflect on the important aspects of relationship development. This valuable process inspired personal growth and encouraged the integration of my past personal experiences with my present professional aspirations. I am confident that the completion of this project will allow me to demonstrate the principles of a strong therapeutic alliance with my future patients and will benefit my future career.
Acknowledgments
I would like to thank my capstone advisor, Debby Givens, PT, DPT, PhD, and my committee members, Mike McMorris, PT, DPT, OCS, FAAOMPT, and Jeff O’Laughlin, PT, DPT, OCS, FAAOMPT, for their guidance during the course of this project. Collectively, you all helped me determine the appropriate scope for the project and identify effective methods for recommending actionable behaviors to my peers and colleagues. Over the course of the DPT program, you all have fostered my professional and academic development. Beyond that, you embody personal and professional characteristics I hope to emulate in the future. Your dedication to the profession and your compassion for those around you is inspiring and will not be forgotten.
Bibliography
- 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 2018:1-13. doi:10.1080/09593985.2018.1516015.
- 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.
- Ferreira PH, Ferreira ML, Maher CG, Refshauge KM, Latimer J, Adams RD. The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Phys. Ther. 2013;93(4):470-478. doi:10.2522/ptj.20120137.
- Moseley GL. A pain neuromatrix approach to patients with chronic pain. Man. Ther. 2003;8(3):130-140. doi:10.1016/S1356-689X(03)00051-1.
Top Image: https://il6.picdn.net/shutterstock/videos/2131433/thumb/7.jpg
9 Responses to “Enhancing the Therapeutic Alliance for Patients with Chronic Pain”
Debbie Thorpe
Dylan
I really like listening to your zoom presentation and the discussion. I am glad that you posted that in addition to your voice thread! Really nice work on this project! This will add nicely to our DPT curriculum in the area of the Therapeutic Alliance.
Best Wishes
dsheedy
Thank you, Debbie. I’m glad my capstone content will be useful for the program going forward. I believe everyone can develop these skills with the appropriate self-reflection and practice. The earlier future clinicians are exposed to this material, the more likely they are to foster positive relationships with their patients!
The recorded Zoom presentation worked out nicely. I am glad to be able to include the thought-provoking discussion since it includes perspectives of my peers and our professors alongside my own.
Conor McClure
Hi Dylan,
Much of my feedback has already been relayed to you directly, but I might as well formally put it down here too, right? I second what Tanner said in his comment: your presentation is definitely something that should be given to first- and second-year students. It contained countless clinical gems that are useful both as a sort of prophylactic measure prior to a clinical rotation and also for reflection upon completion of a clinical rotation.
In a curriculum that necessitates rote memorization of never-ending boluses of information, your Capstone offers a reprieve into the human aspect of healthcare. I guess some of my enthusiasm is simply coming from my own interests in this field, but I always appreciate a departure from the typical science-heavy projects many of us have undertaken. Your work is equal parts evidence-based and experience-based, offering actionable information to both present and future clinicians. Your handout in particular accomplishes this with a unique collection of useful examples and applications. You went above and beyond much of the research in this area, not just telling us how and why this “works,” but how to actually “do” it!
I had the pleasure of attending your virtual presentation and interacted in it quite a bit. I found your presentation style particularly engaging, and I think I’ve told you already, if you were reading off of notes, I couldn’t tell. It was clear that you were prepared and understood your material, while improvising effortlessly and fielding questions and moderating discussion without trepidation. Thanks again for letting me ramble on in my signature unnecessarily-verbose-and-ponderous way. You’ll make a great teacher one day.
Thanks for putting this together. I sincerely hope it inspires future generations of DPT students to consider the importance of therapeutic alliance, patient-therapist relationship, and human experience of healthcare even more.
– Conor
dsheedy
Conor,
Thank you for your kind words and active participation during the presentation. My goal was to provide actionable behaviors and phrases that could be used in the clinic. I find that it’s easy to talk about having a positive relationship with patients, but it is much harder to know how to develop the relationship and handle conflict in real-time. I hope my capstone project will be integrated into the eDPT program in some capacity. Our faculty understands the importance of positive therapeutic relationships, but there is little formal academic content in this area as of right now.
I believe the soft skills of therapy are as important as the technical knowledge, so hopefully this capstone will serve to enhance the soft skills of all future UNC eDPT graduates.
Tanner Holden
Dylan,
I wasn’t able to attend your Zoom presentation due to other course obligations. However, you’re topic was very interesting to me, so I made sure to watch it after you posted and I’m glad I did. You have done an absolutely incredible job with your project. First, I’ll address some of the logistics. Your slides were aesthetically pleasing and the pictures and visuals you used enhanced the delivery of the presentation. You had a good pace throughout and it was clear that you were well-prepared and knowledgeable about the topic. I really appreciated how engaging the presentation was. You appropriately spaced the participation-based slides throughout the presentation and asked questions that were relevant to your main points. Lastly, you fielded comments and questions about your topic like a seasoned-veteran. I’m of the opinion that you should deliver this in-person to future cohorts.
I appreciated how your presentation focused on the contextual factors that affect patient outcomes and gave practical recommendations about what we can do to foster a therapeutic alliance. Throughout the presentation I found myself thinking, “this stuff doesn’t sound that hard to do.” However, the reality is that these concepts aren’t as intuitive to put into practice without intentionally doing so. I loved the practical recommendations you gave on ways to incorporate behaviors that foster therapeutic alliance. Trying to incorporate two behaviors at a time is more actionable and fosters self-reflection so that those behaviors can be mastered—exactly how you intended.
You also make great points about “practitioner resilience” which hit home with me. There have been many times where I’ve gone home from work in the clinic and let an encounter with a patient negatively affect me, emotionally. The strategies that you gave offer a practical way for me to avoid letting patient encounters affect me outside of the clinic. In the same vein, I think the information you presented on resilience has relevance for reducing practitioner burnout.
Thank you for sharing your findings with us. Job well done, Dylan!
dsheedy
Tanner,
Thank you for your feedback regarding the quality of my presentation and the effects it had on you. The goal of the presentation was to spur self-reflection and it seems to have been effective for you, which I am glad to see. I think that developing practitioner resilience will be hugely important for our cohort and future eDPT cohorts. I think there are many ways to practice self-care and improve practitioner resilience, of which my proposed method is only one.
I hope my method of self-reflection is useful for you moving forward. I use this same practice (identifying the root causes of emotional responses, trying to choose my emotional response to a given environmental stimulus) when I am facing conflict in my personal life as well! Can’t wait to see how the practices manifest in your personal and professional life moving forward.
Dylan Sheedy
Jake and Mara,
Thank you for attending my presentation, and thank you for your positive feedback. I am glad to know the presentation was informative and clinically relevant for you all. I recognize that my handout is on the dense side, but I feel all the information is relevant and appropriate – I chose to include more content that would be useful in the clinic instead of reducing content for the sake of increasing negative space.
My goal with the project was to address the “soft skill” components of patient care, so I am glad it was useful in that regard. If we can master the “hard skills” and the “soft skills” then we will be able to provide the highest quality of care for our patients.
jct3de
Dylan,
Excellent job on this project! I really enjoyed listening and participating in your Zoom presentation. You are a really engaging presenter, and I really like how you involved the audience in discussion. The topic you chose is such an important need to address! People with chronic pain have so many complex issues contributing to their condition that need to be considered from a holistic, biopsychosocial perspective. You really brought to life many of the difficulties involved in treating these patients, and provided concrete strategies for mitigating relevant issues that can improve quality of care. Pain neuroscience and patient/therapist alliance are critical components of what we do, and they are difficult topics to teach in PT school. You did an excellent job tackling these complicated issues. Thanks for all the information and helpful suggestions!
argyriou
Dylan, I really enjoyed your Zoom presentation and reading through your capstone materials. You present a topic that is not frequently touched upon in PT but that is so important, and I think a lot of us have recognized that during our clinical experiences. You did an excellent job presenting the evidence, as well as clinical application and techniques/strategies we can use to foster therapeutic alliance in the clinic. While I think the handout can be perceived as wordy, I think all the information presented is pertinent and beneficial. You have given us multiple, straight forward strategies to choose from in the handout, which I think is very effective as we all have different preferences. I definitely plan to use a lot of these strategies in my upcoming clinical and in my further PT career. Thank you, and great job, as per usual!