Therapeutic Alliance: Definition and Implementation into Patient Care

 

Therapeutic Alliance: Definition and Implementation into Patient Care:

By Matthew Chaus, SPT 

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Background: 

Before entering physical therapy school at UNC, I worked at an outpatient orthopedic physical therapy clinic. This clinic saw a large volume of patients of varying diagnoses. This is where I began noticing a distinct pattern with some of the patients. I began to notice that some patients were unresponsive to physical therapy and presented with chronic conditions. As I progressed through the curriculum I was exposed to how multiple different biopsychosocial factors could affect treatment outcomes. It wasn’t until my outpatient orthopedic rotation where my clinical instructor (CI) Dr. James (Quinlon) Curtis PT, DPT, OCS introduced me to the concept of a therapeutic alliance. The majority of the patients we were seeing had long-standing or chronic symptoms and many demonstrated significant biopsychosocial factors. Multiple times throughout the rotation I was educated about how these factors, the words we choose to use, and the relationship the clinician forms can hinder or enhance a patient’s ability to reap the positive benefits from physical therapy. All of these factors were contributing to the therapeutic alliance or working relationship between the patients we saw.

Through multiple discussions with my CI, I realized that there was a need to educate clinicians and students on the importance of considering the relationship we are forming with our future patients. This discussion captivated my interest and thus allowed me to pursue this topic for my capstone project. As part of my Evidence-Based Practice II coursework, I was able to complete a critically appraised topic (CAT) which focused on ways to improve the therapeutic alliance to improve treatment outcomes in patients with chronic musculoskeletal conditions. All of these experiences provided me with a foundation to begin to build my capstone project. My capstone presentation will aim to provide current students and clinicians with advice and current evidence about ways to improve their clinical ability to enhance the therapeutic alliance with their patients.

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Statement of Need:

Chronic musculoskeletal pain is a pressing issue and is highly prevalent in today’s society. One study estimates around 116 million individuals in the U.S alone experience some form of chronic musculoskeletal pain.¹ The estimated cost of providing care to these individuals is approximately $560 billion in direct medical costs, decreased workplace productivity, and associated disability costs.¹  Biopsychosocial and cognitive factors such as stress, catastrophizing, poor coping strategies, and fear-avoidance behaviors are correlated with an individual’s likelihood of developing some form of chronic musculoskeletal pain and prolonging their clinical prognosis.^3,4 As physical therapists, it is of the utmost importance to understand how to address these factors so we can properly acknowledge them within the treatment plan. Treating individuals with chronic musculoskeletal pain is a difficult and daunting task for even the most experienced clinicians. A positive therapeutic alliance can be a significant tool to help enhance treatment interventions.

The Therapeutic alliance is defined as the collaboration, warmth and, support between the patient and the therapist.² Therapeutic alliance (TA) or working alliance has been shown to have a positive influence on treatment outcomes in individuals with chronic musculoskeletal conditions. Certain factors have been identified as either positively or negatively affecting the strength of the TA. The researched benefits of establishing a positive therapeutic alliance include improving disability and pain levels, improving patient adherence and motivation to complete treatment, and improving overall mood and depression levels in patients with chronic musculoskeletal conditions.^2,5-9 Unfortunately, these personality traits or communication factors are underutilized as a large number of clinicians frequently struggle when attempting to form a positive therapeutic alliance with their patients. For this reason, it is important to train clinicians on how to improve their ability to form a positive therapeutic alliance with their patients to improve the quality of care patients with chronic conditions receive.

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Purpose:

When discussing communication skills with multiple therapists I often heard the response, individuals either have the necessary skills to communicate effectively or they don’t, there is no in-between. The purpose of this project is to educate current physical therapy students and working clinicians about the importance of establishing a positive therapeutic alliance with patients and how to improve their clinical ability to form this relationship. I believe that communication skills can be improved just as one improves their clinical skills through practice and exposure. The goal of this educational presentation will be to help others with tips on how to improve their therapeutic communication and overall relationship with the patients they treat.

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Products:

This project began in the Evidence-Based Practice II course with a critically appraised topic (CAT). My topic for the CAT focused on treatment outcomes in patients with chronic low back pain and compared these outcomes with patients who had a positive vs negative therapeutic alliance between their clinician. This help set the foundation for beginning to work on my capstone project which is a VoiceThread presentation that will be used as a supplemental resource for DPT students enrolled in PHYT 750 Psychosocial Aspects of Disability and Illness class along with working clinicians.

The final product will include demonstrations of specific examples of how verbal communication can help or hurt patient outcomes, examples of how to establish a positive therapeutic alliance between clinicians and patients, the researched benefits for why establishing a positive therapeutic alliance is important, and advice on how to integrate these traits into current practice. Along with the CAT and VoiceThread presentation, I have included an evidence table with the evidence used to support my presentation. Each of these products can be viewed in the links below. 

Therapeutic Alliance VoiceThread

Therapeutic Alliance VoiceThread (YouTube link)

CAT Therapeutic Alliance

Evidence table Capstone

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 Evaluation:

Throughout the process of creating this project, I sought out constructive feedback from my capstone advisor Dr. Deborah Thorpe, PT, PhD and my committee members Dr. Jon Hacke, PT, DPT, OCS and James (Quinlon) Curtis PT, DPT, OCS. Their valuable feedback allowed for the development of the project, editing my presentation, and proper logistical planning as needed. Because this product is largely intended for first-year physical therapy students in PHYT 750 and working clinicians I will not be able to solicit real-time feedback. I have created an evaluation survey that will enable me to access the feedback, assess if my presentation was beneficial in meeting the learning objectives, and allow feedback for future projects or presentations. The link is posted below.

Therapeutic Alliance Capstone Presentation Evaluation Form

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Self-Assessment:

I believe that I put a considerable amount of time and effort into this project as it was a topic of interest to me. I believe that this topic is not only interesting but also extremely important to acknowledge and constantly work to improve during our clinical care of patients. This project taught me a great amount about the benefits and impact personality traits and communication has on patients.  During the process this project also allowed me to become more proficient at critically analyzing the evidence once a clinical question has been developed. While I learned a great amount about research and putting evidence into practice I still believe there is much that can be improved. I will be looking forward to the feedback provided as an opportunity to improve my presentation skills as I hope to one day become a clinical instructor and help future students as my clinical instructors have helped me. Looking back, I wish that I could have given this presentation in person to receive feedback from a student’s perspective. This would have been valuable feedback; however, I will utilize the feedback from students who watch the presentation to enhance future presentations/projects. Overall, I am happy with how this project turned out and conclude that it will be beneficial for beginning to educate students and clinicians about the importance of developing a positive therapeutic alliance with patients.

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Acknowledgment: 

First and foremost, I would like to acknowledge and thank my capstone advisor Dr. Deborah Thorpe, PT, PhD and my committee members Dr. Jon Hacke, PT, DPT, OCS and James (Quinlon) Curtis PT, DPT, OCS. Without their feedback, direction, and in-depth conversations this project would not have been possible. Each of these individuals has motivated me to become a better clinician and provide the highest quality of care possible and for this, I am extremely thankful.

I would also like to give a special thank my amazing wife Alizabeth who has done nothing but support me through all the ups and downs of physical therapy school. Thank you for the constant hours of being my practice patient, listening to my practice presentations, and providing input and suggestions as needed.

Last and certainly not least I would like to acknowledge my classmates and all of the faculty members in the UNC DPT program. Each of you has been motivating and encouraging throughout this entire process and has inspired me in one way or another. This project would not have been possible without the guidance, motivation, and comical relief that made this journey so memorable.

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References:

1. Lamerato LE, Dryer RD, Wolff GG, Hegeman-Dingle R, Mardekian J, Park PW, Zlateva G. Prevalence of chronic pain in a large integrated healthcare delivery system in the U.S.A. Pain Pract.2016;16(7):890-898. doi:10.1111/papr.12334.
2. 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.  Ther.2013;93(4):470-478. doi:10.2522/ptj.20120137
3. Pincus T, Burton AK, Vogel S, Field AP. A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine2002;27(5):E109-20. doi:10.1097/00007632-200203010-00017.
4. Stewart M, Loftus S. Sticks and stones: the impact of language in musculoskeletal rehabilitation. 2 Orthop. Sports Phys. Ther.2018;48(7):519-522. doi:10.2519/jospt.2018.0610 .
5. 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.  Ther.2010;90(8):1099-1110. doi:10.2522/ptj.20090245.
6. 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.  Theory Pract.2018:1-13. doi:10.1080/09593985.2018.1516015.
7. Vong SK, Cheing GL, Chan F, So EM, Chan CC. Motivational enhancement therapy in addition to physical therapy improves motivational factors and treatment outcomes in people with low back pain: a randomized controlled trial.  Phys. Med. Rehabil.2011;92(2):176-183. doi:10.1016/j.apmr.2010.10.016.
8. Lakke SE, Meerman S. Does working alliance have an influence on pain and physical functioning in patients with chronic musculoskeletal pain; a systematic review. J of Compassionate Health Care2016;3(1):1. doi:10.1186/s40639-016-0018-7.
9. Fuentes J, Armijo-Olivo S, Funabashi M, Miciak M, Dick B, Warren S, Rashiq S, Magee DJ, Gross DP. Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: an experimental controlled study.  Ther.2014;94(4):477-489. doi:10.2522/ptj.20130118.