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Therapeutic Alliance – Three Steps

Three Steps to Achieving a Therapeutic Alliance

This term has gotten a lot of attention recently as the entire U.S. healthcare system begins to move ever so gradually towards a value-based payment model. I think it will be clear to everybody that we will not be able to simply “procedure” people better. At some point we are going to have to engage the patient in a process that ensures their participation in their own health. Whether it is in a rehab context where somebody is trying to recover from an injury or in a general health management environment, it’s clear that building a relationship is the cornerstone to a healthier population.

For those of us in physical therapy, it’s common to think our only task is to help patients recover from or prevent an injury. We can easily get caught thinking that what we “do” to the patient will be enough to get a successful clinical outcome when in fact, it can be very difficult to achieve successful outcomes without the patient’s participation. 

This might go without saying, but consider this example;

I can do the perfect mobilization on somebody’s lumbar spine and prescribe the best possible exercises to improve the local and global physiology, however unless the patient actively participates by transferring the benefits gained in the clinic into their environment, the chances for my success diminish greatly. So, how can you increase your chances of success? Read on to find out.

How do we get people to do what they are supposed to do to get better?  

The short answer? We can’t. People have to choose to get better. The long answer? We can be the ones who help people make the choice to get better. Aha! That is Jedi level physical therapy.

The therapeutic alliance provides a useful starting point. And to understand the concept fully, we must reach across the aisle to our colleagues in psychology. The idea of the therapeutic alliance can be traced back to Sigmund Freud and his theory of transference whereby there is an unconscious redirection of feelings from the patient to the therapist and from the therapist to the patient[1]. 

In the 1950s, Carl Rogers, the father of client-centered therapy, outlined the components of the therapeutic alliance[2], specifically:

  • empathy, 
  • congruence and 
  • unconditional positive regard.

Early psychologists in the field of patient-centered therapy proposed that “if the patient is convinced of the therapist’s competence and adherence, this will give the latter the necessary influence to bring about changes in the patient” [3]. Edward Bordin[4] iterates that the strength, not the kind of working alliance will make the difference in therapy. He goes on to say that “the working alliance between the person who seeks change and the one who offers to be a change agent is one of the keys, if not the key, to the change process” [4]. He further suggests that the working alliance is universal, not limited to the context to psychotherapy, but in all context whereby one desires to change and seeks help from others. It applies to a student and a teacher, an employee and a manager and of course between a patient and a provider. 

The field of psychology, in spite of its many different approaches to achieving a successful clinical outcome, recognized that the foundation of any technique performed by the therapist was underpinned by the success of the alliance between the patient and the provider. Sound familiar? It seems that physical therapists are now grappling with some similar issues. There are many different techniques that we can employ as physical therapists. In fact, there are certifications for multiple different treatment modalities that include taping techniques, tools and needles. While each of them provide some therapeutic value, none of them can fully explain the outcome and all of them must be applied in the context of a therapeutic alliance. Without this context, we fail to provide the essential element of the therapeutic engagements. 

How can we do this? Let’s consider some practical applications to the concept. To achieve a therapeutic alliance you need three components.

1. Agreement on the goals of the treatment

This means that as a physical therapist, I would have to arrive at agreement with the patient’s goals. In a perfect world this would be easy, but how many times have you been faced with an inability to agree on the patient’s goals? In my practice, I’ve seen this happen many times. I think that the patient’s goals are either unachievable or, in some circumstances, that the patient is capable of so much more. Without alignment, the rest of the engagement is likely to fail.  It is a skill to establish this alignment. The first step is understand the reasons behind a patient’s goals and the beliefs driving the goals. It provides a specific challenge when the beliefs underlying the desire for the goal are in conflict with reality. There are some specific ways to resolve this conflict to ensure that the alliance is established.

2. Agreement on the pathway to the goals or the tasks required to accomplish the goals.

This is one of my favorite questions during my initial visit with the patient. “What do you think will be required for you to achieve these goals?” It is a brilliant question to  understand the patient’s perspective on what they are going to have to do and what they’re expecting me to do. It will allow me to determine how much work I have to do in order to close the gap of that perception. The success in this step requires exceptional communication: listening and watching carefully to determine congruency.

3. Unconditional positive regard. 

I’ll be honest, this can be tricky. As humans, we all have opinions and feelings about things – patients, co-workers, managers, the person we see at Starbucks every morning. Quite frequently we struggle to develop positive feelings toward a person for many reasons. This is not to be considered bad per se but rather a fact of being human and a possible barrier to truly connecting with that individual. Think of a specific example of a patient that when you look at your daily schedule you say to yourself “huuuh, they’re on my schedule again.” This is normal but it is our ability to recognize and work with these feelings that make the difference in the patient encounter.  

As we move towards a value-based payment model, our ability to engage patients in a manner that inspires them to participate in their own care will make the difference between the therapists who succeed and those who do not. A fundamental element of a successful patient outcome will be the Therapeutic Alliance – and it’s something we should all get very good at.

  1. Horvath A. O., Luborsky L. (1993). The role of the therapeutic alliance in psychotherapy. J. Consult. Clin. Psychol. 61, 561–57310.1037/0022-006X.61.4.561 [PubMed] [CrossRef] [Google Scholar]
  2. Rogers C. R. (1951). Client-Centered Therapy. Boston: Houghton Mifflin [Google Scholar] [Ref list]
  3. Ardito, R. B., & Rabellino, D. (2011). Therapeutic alliance and outcome of psychotherapy: historical excursus, measurements, and prospects for research. Frontiers in psychology2, 270. doi:10.3389/fpsyg.2011.00270
  4. Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16(3), 252–260. doi:10.1037/h0085885


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Therapeutic Alliance – Three Steps