In our first two posts, we examined the patient and the therapist as foundational contextual factors influencing clinical outcomes. Now, we turn to the space between these two individuals—the therapeutic relationship—a dynamic, co-created alliance that profoundly shapes the course of treatment.

Physical therapy is not just a technical delivery of procedures and techniques. It is a human interaction built on communication, trust, and shared meaning. Researchers consistently confirm that the strength of the therapeutic relationship is one of the most powerful predictors of treatment success, especially in musculoskeletal care [1]. When the therapist and patient form a strong, collaborative bond, clinical outcomes improve [2] even independent of the specific techniques used.

What is the Therapeutic Relationship?

The therapeutic relationship, also called the therapeutic alliance or working alliance, refers to the collaborative and trusting relationship that develops between a healthcare provider and a patient. Drawing from Bordin’s foundational model, it consists of three core elements:

1. Bond – The emotional connection, mutual respect, and trust that foster emotional safety.

2. Agreement on Goals – Shared understanding of the desired outcomes of therapy.

3. Agreement on Tasks – Collaboration on the methods and interventions used to achieve those outcomes.

This relationship is not static; it evolves over time and is influenced by every verbal and nonverbal interaction [2]. When these components are strong, the patient and therapist are truly working with each other, creating a synergistic effect that enhances every other aspect of care.

Why the Therapeutic Relationship Matters for Outcomes

The alliance is not just an ethical ideal, it is a measurable, evidence-based determinant of outcomes. A robust body of literature supports that a high-quality therapeutic relationship correlates with:

• Reduced pain and disability

• Greater adherence to home exercise programs

• Lower dropout rates and improved attendance

• Higher patient satisfaction and trust

Research in chronic low back pain has even demonstrated that the strength of the therapeutic alliance is a better predictor of functional outcomes than the specific interventions applied. In a landmark study by Fuentes et al., patients who received a sham intervention paired with an enhanced alliance had better outcomes than those receiving real interventions in a neutral relational context [4]. This suggests that the context of care, how it is delivered, can amplify or undermine the effects of treatment.

The alliance also influences biological pathways. A supportive, empathetic interaction can trigger placebo responses, promote the release of endogenous opioids and oxytocin, and reduce cortisol and anxiety. Conversely, cold or dismissive encounters can evoke nocebo effects, exacerbating pain and stress responses [5].

Factors That Enhance or Erode the Therapeutic Relationship

Factors That Enhance:

• Active listening and empathy

• Collaborative goal-setting

• Clear, consistent communication

• Respect for autonomy and lived experience

• Personalized care

Factors That Erode:

• Rushed or inattentive interactions

• Dismissive or invalidating comments

• Misalignment of goals or tasks

• Rigid, clinician-centered approaches

Every session is a micro-opportunity to strengthen or fracture the alliance. The most effective therapists understand that the alliance building with the patient is the foundation upon which an effective treatment is delivered [2].

Clinical Application: Building the Therapeutic Relationship

1. Establish the Bond Early

Begin by cultivating emotional safety. Greet patients warmly, maintain eye contact, and demonstrate genuine interest in their story. Small behaviors—recalling a patient’s hobbies, offering reassurance, or validating their pain experience—signal that they are seen and valued. These actions regulate emotional arousal and foster trust.

2. Negotiate Shared Goals

Move beyond standardized functional outcomes and ask what truly matters to the patient. What activities do they want to return to? What fears or barriers do they perceive? By integrating their values and priorities into the treatment plan, you align therapy with intrinsic motivation.

3. Collaborate on the Therapeutic Tasks

Invite participation in care decisions. Offer treatment options and ask for preferences. Instead of issuing directives, ask, “What do you believe would be most helpful?“ And, when the patient is not sure, ask,  “Would you be willing to try this?” This approach fosters autonomy and increases adherence. It also reduces the likelihood of resistance, which often stems from a lack of perceived control.

4. Maintain the Alliance Over Time

Check in regularly about the relational process: “How are we doing together?” “Are we heading in the right direction?” When difficulties arise—such as missed visits, frustration, or stagnation—address them openly. Ruptures in alliance are inevitable, but when repaired skillfully, they can actually deepen trust and partnership [6].

A Real-World Example

Consider a patient presenting with persistent neck pain following a minor car accident six months ago. The patient has developed fear of movement, avoids driving, and has visited multiple providers with minimal relief. One therapist quickly attributes the issue to poor posture and provides a standard set of exercises with minimal dialogue.

Another therapist takes time to understand the patient’s lived experience—listens to their story, explores their fears, and helps them understand the relationship between stress, muscle tension, and pain. They validate the patient’s frustration, educate with empathy, and invite them into a gradual exposure plan that feels safe and manageable.

Which therapist is likely to foster stronger engagement and trust? The second therapist builds an alliance that supports not only physical recovery but emotional resilience. They’re not just addressing neck pain—they’re addressing the person with neck pain. The therapeutic relationship becomes the context through which true recovery begins.

Why This Matters in Everyday Practice

In an era that often values productivity and throughput, investing in the therapeutic relationship may seem like a luxury. In reality, it is an evidence-based strategy for improving outcomes, increasing adherence, and enhancing patient satisfaction. It also enriches the clinician’s experience, transforming care into a meaningful collaboration.

The relationship building is not a soft skill, it is a core clinical competency.

What’s Next in the Series

In the next post, we’ll explore The Treatment as a contextual factor—examining how the framing, delivery, and perceived credibility of an intervention influence its impact.

This series continues to highlight not just what we do in physical therapy, but how we do it—and how every aspect of the clinical encounter matters.

Try the following

As you reflect on your own clinical practice, consider:

• How would you rate the strength of your therapeutic relationships?

• What skills do you use to foster trust and collaboration?

• Where might you improve the way you connect with your patients?

Improving the therapeutic relationship is not about adding more to your plate, it’s about developing and using the skills to become more intensional with what you are already doing to create better connections. Invest in the relationship, and you invest in better outcomes.

Stay tuned for Part 4: The Treatment.

References:

1. Babatunde, F., MacDermid, J., & MacIntyre, N. (2017). Characteristics of therapeutic alliance in musculoskeletal physiotherapy and occupational therapy practice: a scoping review. BMC Health Services Research, 17(1), 375.

2. Arrigoni, A., Rossettini, G., Palese, A., Thacker, M., & Esteves, J. E. (2024). Exploring the role of therapeutic alliance and biobehavioural synchrony in musculoskeletal care: Insights from a qualitative study. Musculoskeletal Science and Practice, 73, 103164.

3. Ferreira, P. H., Ferreira, M. L., Maher, C. G., Refshauge, K. M., Latimer, J., & Adams, R. D. (2013). The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Physical Therapy, 93(4), 470–478.

4. Fuentes, J., et al. (2014). Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: an experimental controlled study. Physical Therapy, 94(4), 477–489.

5. Rossettini, G., Camerone, E. M., Carlino, E., Benedetti, F., & Testa, M. (2020). Context matters: the psychoneurobiological determinants of placebo, nocebo and context-related effects in physiotherapy. Archives of Physiotherapy, 10, 1-12.

6. Miciak, M., & Rossettini, G. (2022). Looking at both sides of the coin: addressing rupture of the therapeutic relationship in musculoskeletal physical therapy/physiotherapy. Journal of Orthopaedic & Sports Physical Therapy, 52(8), 500-504.