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FOTO Rehab Outcomes Blog

Characteristics of Therapeutic Alliance

I appreciate the buzz that continues to grow around the topic of therapeutic alliance. I dislike that often times discussions focus on empathy.  Empathy has a role, sure, but empathy isn't the main factor. 

The study I am sharing is fantastic in really creating the big picture about what a therapeutic alliance really is. Table 4 has 8 core themes that are part of a therapeutic alliance. Then, the table shares 44 additional aspects within the core themes. Therapeutic alliance includes roles for not only the clinician, but also the patient. A therapeutic alliance obviously includes creating a relationship while at the same time agreeing on goals, good communication skills, measuring outcomes, and individualizing sessions based on how the patient presents for the day.  I like how roles were defined and the prerequisites that are required by both the clinician and the patient.

For some reason, clinicians tend to focus on the patient behaviors such as attending services and performing home exercise programs. We skip over our behaviors. Let's take for example my clinic day the other day. I was just about to begin a session with a gentleman who recently underwent elective surgery for a total knee arthroplasty. It isn't going as should be expected at this point in time... when in through the doors walks in a previous patient I hadn't seen in about a year. He stopped in to give me a hug, introduce me to his daughter and let me know his wife is in a home for individuals with dementia (so I could pop in and visit her) and that he was just diagnosed with bladder cancer. Of course, I spent a bit of time with him and then went on to treat the patient waiting for me. Then, with that patient, for some reason, the surgeon did not use a drain tube after the procedure. I have a feeling the reason that we aren't making gains (even though he's working his tail off) has to do with joint effusion. I contacted his surgeon's office to provide an update and request the patient have a follow up visit to have a potential joint aspiration. I engaged in about 4 phone calls after that due to misperception and a patient who wasn't having his expectations met due to previous conversation with the surgeon on a follow up visit. And then, toward the end of my day, the son-in-law of a previous patient stopped in to introduce me to his grandchildren (a 4 year old girl and a 2 year old boy). A few years back I had emergency services whisk his father to the hospital. His father had presented with a change in condition that had me concerned.  And then, the last patient of the day (a young 35 year old female) wasn't indicating a level of improvement I would have expected. Thankfully, right after I said, "I'm missing something. I really need your help. You aren't responding as I had anticipated. We need to talk to figure out why," she immediately stated, "what about ticks?" She moved to Michigan a few years ago, but prior to that she lived in Delaware and removed ticks daily. About 5 years ago, she had one festered and infected in her shoulder blade region. So... another call and differential diagnosis recommendations for diagnostic testing.  What's really sad: she had been treated for a bit over a year with no results. 

Please take a look at the full study. You'll learn that therapeutic alliance is far more than just patient's being motivated and attending their scheduled visits. You have a role and certain behaviors that influence therapeutic alliance.

Below you will find a quick view of the abstract. 


Characteristics of therapeutic alliance in musculoskeletal physiotherapy and occupational therapy practice: a scoping review of the literature.




Most conventional treatment for musculoskeletal conditions continue to show moderate effects, prompting calls for ways to increase effectiveness, including drawing from strategies used across other health conditions. Therapeutic alliance refers to the relational processes at play in treatment which can act in combination or independently of specific interventions. Current evidence guiding the use of therapeutic alliance in health care arises largely from psychotherapy and medicine literature. The objective of this review was to map out the available literature on therapeutic alliance conceptual frameworks, themes, measures and determinants in musculoskeletal rehabilitation across physiotherapy and occupational therapy disciplines.


A scoping review of the literature published in English since inception to July 2015 was conducted using Medline, EMBASE, PsychINFO, PEDro, SportDISCUS, AMED, OTSeeker, AMED and the grey literature. A key search term strategy was employed using "physiotherapy", "occupational therapy", "therapeutic alliance", and "musculoskeletal" to identify relevant studies. All searches were performed between December 2014 and July 2015 with an updated search on January 2017. Two investigators screened article title, abstract and full text review for articles meeting the inclusion criteria and extracted therapeutic alliance data and details of each study.


One hundred and thirty articles met the inclusion criteria including quantitative (33%), qualitative (39%), mixed methods (7%) and reviews and discussions (23%) and most data came from the USA (23%). Randomized trials and systematic reviews were 4.6 and 2.3% respectively. Low back pain condition (22%) and primary care (30.7%) were the most reported condition and setting respectively. One theory, 9 frameworks, 26 models, 8 themes and 42 subthemes of therapeutic alliance were identified. Twenty-six measures were identified; the Working Alliance Inventory (WAI) was the most utilized measure (13%). Most of the therapeutic alliance themes extracted were from patient perspectives. The relationship between adherence and therapeutic alliance was examined by 26 articles of which 57% showed some correlation between therapeutic alliance and adherence. Age moderated the relationship between therapeutic alliance and adherence with younger individuals and an autonomy support environment reporting improved adherence. Prioritized goals, autonomy support and motivation were facilitators of therapeutic alliance.


Therapeutic Alliance has been studied in a limited extent in the rehabilitation literature with conflicting frameworks and findings. Potential benefits described for enhancing therapeutic alliance might include better exercise adherence. Several knowledge gaps have been identified with a potential for generating future research priorities for therapeutic alliance in musculoskeletal rehabilitation.

2017 May 30;17(1):375. doi: 10.1186/s12913-017-2311-3.