4 Conversations That Are a Sign of a Strong Therapeutic Alliance

A therapeutic alliance is key to effective treatment of a patient in rehab therapy. Originally used in psychology and psychiatry, the therapeutic alliance is a combination of a collaborative patient-therapist relationship, an affective bond between the two, and their ability to align on goals and outcomes of the treatment. The therapeutic alliance is integral in making sure both parties are engaged in the process of therapy, thus prompting better patient outcomes.

Building a therapeutic alliance requires work and input from both the physical therapist (PT), occupational therapist (OT), or speech-language pathologist (SLP) and the patient. Here are some conversations you should be having in order to construct and maintain a strong therapeutic alliance.

1. Agreement on Treatment Duration

There’s nothing worse than outlining a 15-week episode of care for a new patient, just for them to no-call, no-show for their next four appointments. That’s why you can start right at intake to build a strong therapeutic alliance—and why agreement on treatment duration and frequency should be one of the first conversations you have with a patient.

Building a rapport starts with both of you having an understanding of and respect for each other’s schedules and expertise. You know the optimal schedule to heal the patient’s injury or reduce their pain, and they know what they’re capable of showing up for and doing at home. The patient, in an ideal situation, is enthusiastic about their work and willing to show up for your schedule and cadence. But even in ideal situations, patients have work obligations, vacations, kids, and other things that need to be worked around.

In this case, the best way to build that therapeutic alliance is to start laying out the options. In this case, it’s a good idea to ask their limitations early, if not right away. Without pressure, ask them how many days a week they might be able to come in for an appointment and how many they’re able to do a home exercise program. If you’re working in a hospital or other in-patient facility, this part will probably be pretty easy.

Once you know their availability, you can work around that to match the optimal episode of care to their specific circumstance. The therapeutic alliance benefits from you working together to accomplish the shared goal of scheduling the program.

2. Understanding of Functional Progression

You know that a plan, even when you lay it out taking everything you possibly could into account, can often go off the rails. That agreement made at the beginning of treatment, ideally at intake, can fall to the wayside as life happens or other responsibilities take away from patient engagement in the process. This isn’t unusual, and doesn’t have to be that detrimental to the patient’s healing. However, you can use various tools and technologies to compare the patient’s progress to expectations set at intake. If that measure is drastically different, it might be time to rethink things.

It’s okay to need to revisit the treatment plan, and it doesn’t have to mean that the therapeutic alliance is damaged. In fact, this can be an opportunity to continue strengthening the therapeutic alliance. Research shows that social bonding occurs when people are focused on the same task and have a shared goal, making adjusting the treatment plan an ideal problem to solve collaboratively.

Make sure that you have the data to show the patient your position when you bring up the conversation. You can explain, “This is where you are now, this is where we want you to be, and this is how we talked about getting there.” Positioning their outcomes as a team effort helps foster that partnership that the therapeutic alliance represents. Knowing how they contribute can beneficially shift the patient’s perception of therapy and be enough to change the way they’re participating in the program.

It might be that the patient isn’t hitting their goals because they haven’t been convinced that the work they do at home is helping attain them. This conversation can be enough to renew their buy-in. But if the problem rests somewhere else, there are a few things you can try.

• Change the cadence of the episode of care
• Extend the treatment plan to accommodate the new time to reach patient goals
• Adjust the prescribed exercises to match what the patient will actually do
• Re-examine the patient’s goals to ensure they still match what the patient wants out of their therapy
• Ask the patient if there’s anything else they want to work through that might be affecting their progress

Tackle it together, and you’ll strengthen the therapeutic alliance even further.

3. Discussion of Treatment Effectiveness

So, we’ve talked about how to address the situation if the patient is falling off track, but what happens when you disagree about how treatment is progressing? Genuine conflict can put a true strain on the therapeutic alliance you’re both working hard to maintain. You are still the expert here, and you can tell, both from data and best practices, what the general recommended options are. But your patient is the one who is dealing with the pain and limited mobility, so it’s always important to remember that their experience is critical.

Let’s look at a few causes for that disagreement and figure out how to remedy the situation in a way that’s beneficial to the therapeutic alliance.

The Patient Thinks They’re Not Progressing as Fast as They Should Be

First, let’s talk about what happens when a patient thinks their progress isn’t moving as fast as they think it should be, even when their progress is actually right where you think it should be. This is common, and it makes sense—rehabbing an injury, especially if you’re an athlete or needing to learn how to walk again, is incredibly frustrating when you can’t do what you want to be able to do.

But, as the therapist, you know they’re actually right on track. So, how do you resolve the discrepancy?

For some patients, data can do it. If they’re not used to injury recovery, they may have warped expectations of the timeline that can be resolved by simply showing them that they’re exactly on pace for the timeline that’s expected for their concern. But not all patients are that easily convinced. And often, the way to alleviate this is to address the frustration, not to adjust the therapy.

The patient doesn’t need to work harder; you just need to help them manage their frustration. This is where your partnership can be key; you’re on the patient’s side, you understand and acknowledge their feelings, and you’ll work together to solve them.

The Patient Isn’t Progressing as Fast as They Think They Are

This one is a bit more difficult. It’s a mismatch of expectations, but in this case, you’re the one who has to make sure they’re aware of the reality of the situation. The trick here is to do it in a way that preserves their enthusiasm while also ensuring they know what their realistic limitations are.

This is another situation where leaning into your existing relationship will work in your favor, and, in turn, strengthen the bond further. Make it clear that their positive attitude is great—and genuinely helping them heal—but that there are a few things they need to look out for. Clarify their physical limitations based on the state of their recovery (as well as the boilerplate, “if it hurts, stop doing it”), as well as letting them know that they are right in the expected timeline. You don’t have to tell them that they’re not ahead of schedule, but it’s also a good idea to avoid confirming their impression.

Make sure to keep your sessions encouraging and focused on the progress they have made, and you should be able to manage expectations without dimming their expectations.

You Think the Patient Is Capable of More Progress

The difference in expectations here is actually kind of all yours—it’s the difference between the expectations you had when the patient started treatment and the expectations you have now that you’ve seen them at work. The good news is, the fix here is simple. A conversation between you and your patient on updating the plan to reflect their progress and how they’ve been improving is probably all you need. And it’s still doing its job to serve the therapeutic alliance. The patient knows you have their best interest at heart, and you’re willing to change your plans because of it.

Addressing these issues collaboratively helps build a strong therapeutic alliance, shows the patient you’re on their side, and promotes healthy conflict resolution that will be critical in your overall practice.

4. Alignment on Discharge Timeline

When it’s time for a patient’s therapy to be done, there’s still an opportunity to develop the therapeutic alliance further. Creating a lasting relationship with your patient is a side effect of a strong therapeutic alliance, but it also helps to establish that trust in case the patient needs treatment again in the future (or they know someone else who does).

While you might have a disagreement on when the patient is actually done with treatment, as we’ve discussed a bit above, there are some easy things you can do to leave your partnership on a high note when the patient is truly ready for their last session.

• Ask the patient how they’re feeling: This can be open-ended so that there is no pressure to provide a right or wrong answer
• Address the patient’s outstanding concerns: Even though they feel ready to continue on without your support, they might still have questions about what they can do on their own
• Discuss any limitations: They may have been through a full course of PT or OT, but not all conditions can be fully resolved, so make sure to address any lingering things they should keep an eye on
• Clarify warning signs: Make sure the patient is aware of any signs that their injury is returning or worsening
• Describe ongoing expectations: You have no direct control over what a patient does while they’re at home, but you can give them some tips on what to continue doing after therapy is over to stay healthy

This final conversation can help the patient remember that even when they aren’t coming in for continual sessions, you are still supporting them and their progress. Addressing their questions and concerns means you’re still collaborating and aligning on their goals, a key tenet of the therapeutic alliance.

The Therapeutic Alliance: The Cornerstone of Therapy

Developing a therapeutic alliance is key to better outcomes for your patients. The more you’re working together towards their goal (or rather, your shared goal), the easier developing that alliance becomes. Collaborating on progress is made all the simpler with data to back up your best practice knowledge and experience. When you can quantify how they’re doing and how you would expect them to perform, you can catch concerns early and work together to solve them. The right technology can help you gather this data and build a more human connection.