Read Full Text: Characteristics of therapeutic alliance in musculoskeletal physiotherapy and occupational therapy practice: A scoping review of the literature
Journal: BMC Health Services Research
Year Published: 2017
Ranked 92nd on our 2016-2021 list of the 100 Most Influential OT Research Articles
CEU Podcast: Relationship-based OT Care with Rafi Salazar
There’s a good chance that you learned about “therapeutic use of self” during OT school. But, it’s just one of many frameworks that consider the relationship between therapists and patients.
This week’s article orients you to more of these relationship models.
This is not just fluffy, feel-good stuff. The therapist-client relationship is a core aspect of OT delivery, and improving these relationships seems to have the potential to improve our clients’ outcomes.
I’m excited to hear how you frame your own relationships with your clients!
Let’s dive in.
Why was this paper written?
This paper focuses on the therapist-client relationship in musculoskeletal OT/PT, and it correctly notes that our treatment effects tend to show, at best, “moderate” effects with this population. That means there is clearly room for improvement.
The authors believe we need to look beyond condition-specific interventions as we strive to improve our care. Instead, they suggest that we look more closely at general “mediators” of care—in particular, the power of the relational aspects of care, which they call “therapeutic alliances.”
How the article defines “therapeutic alliance”
The article describes the “therapeutic alliance” as the working relationship between the patient and therapist. This relationship is established through:
- Collaboration
- Communication
- Therapist empathy
- Mutual respect
The authors highlight the belief that the therapeutic alliance can be used in all therapy episodes, regardless of specific treatment modality. Three essential parts of the therapeutic alliance have been suggested:
- Agreement on the goals of treatment
- Agreement on the tasks
- Development of a personal bond between therapist and client
What methods were used to study therapeutic alliances?
If you are like me, you instantly get what the authors are talking about…but you might not have ever used the phrase “therapeutic alliance.” That’s OK! There are lots of different phrases out there to describe the patient-client relationship.
So, step one to studying this concept was to do what is called a “scoping review” of literature. The authors explored how therapeutic alliances may have been already conceived of and studied—even if the terms used were slightly different. The real aim of this scoping review was to map the current landscape of research around the frameworks, themes, and measures related to therapeutic alliances in musculoskeletal OT and PT.
What settings/conditions were the most studied
130 articles met the inclusion criteria. The articles ranged from randomized control trials to reviews and discussions.
The most reported upon settings were outpatient (25%) and primary care (34%). Spinal conditions (25%) and joint deterioration (21%) were the most reported health conditions across studies.
What frameworks, theories, and models related to therapeutic alliance were identified?
In an attempt to summarize the current theoretical underpinnings of therapeutic alliances, the authors combed the articles and found the following frameworks, theories, and models.
I’m going to link to a description of the ones I can find, so you can dig deeper into the ones that pique your interest!
19 Models
- Biopsychosocial model
- Consumer model
- Ecological model of adherence
- Gelso and Cater model
- Health belief model
- Health locus of control
- Hobfil’s resource conservation model
- Independent living model
- Information-motivation-behavioral model
- Levanthal’s self-regulation model
- Model of empathic understanding
- Model of helping-encounter
- Model of human occupation
- Model of physiotherapist-patient interactions
- Process model of collaboration
- Self-management model
- The Intentional Relationship Model
- Transtheoretical theory
- Tripartite efficacy model
12 Frameworks
- 5As framework of health behavior change
- Behavioral theory-based strategies for enhancing patient treatment cooperation and patient beliefs
- Building blocks of health behavior change
- Client satisfaction
- Compliance and satisfaction with exercise
- Dimensions of helping
- Model of health change
- Patient centered care
- Productive partnership framework
- Therapeutic use of self
- Tripartite efficacy framework in client-therapist rehabilitation interactions
- Understanding of illness
3 Theories
What assessments were used to measure the strength of the therapeutic alliance?
I was surprised by the number of assessments that measure the patient-therapist relationship! The article listed about 15. Below, I’m linking the two that seemed accessible to practicing OTs!
I can see these as being useful tools to check in on the health of your relationships with clients—or, even as a good conversation-starter for when you have a difficult patient relationship.
How does therapeutic alliance impact outcomes?
The article did not fully delve into this, as its main aim was to map the available research out there. But, the authors did provide some general thoughts and trends for you to consider.
The relationship between therapeutic alliance and treatment adherence (TA) seems to be the most studied outcome. The authors state that there is promising evidence in several health disciplines beyond just physical rehab, such as general medicine and psychotherapy.
There was limited evidence to review that was specific to occupational therapy, but the authors concluded from PT literature that the therapeutic alliance seems to have diverse impact on treatment adherence. The therapeutic alliance may serve as a predictor, moderator, and mediator, and should not be discounted as a strong influencer of patient outcomes.
Other outcomes of note were that were found in individual studies:
- Therapeutic alliance was correlated with improved function, as well as reduced disability and pain.
- Therapeutic alliance was found to be more strongly associated with function and outcomes than pain.
Authors’ conclusion and recommendations
The authors concluded that “enhanced TA has some beneficial effects on treatment adherence.” They suggest that next steps for research would be to develop a physical rehab-themed framework for the therapeutic alliance.
Takeaways for OT practitioners
(These are my own takeaways and were not mentioned specifically in the article.)
1. There are many different ways to conceive of the therapist-client relationship.
This article really expanded my thinking of the therapeutic alliance beyond “therapeutic use of self.” And, honestly, since this article was just focused on outpatient musculoskeletal therapy, just think how many more frameworks may be out there if you investigated similar research in mental health or pediatrics.
And, what’s interesting about this early stage is that we strongly suspect therapeutic alliances are important to outcomes—but there isn’t one particular right way to conceive of that relationship, so you can choose the one that feels right to you.
2. I personally thought the language of relationship-based care was the most helpful.
The research we’ve studied over the past few years has pushed us to think of ourselves more as partners guiding our clients toward self-management. Articles like the ones listed below had already started to shift my thinking on the patient-client relationship:
- eHealth, participatory medicine, and ethical care
- Self-Management Support Interventions for Stroke Survivors
- Occupation-Based Coaching by means of telehealth for families of young children with autism spectrum disorder
But, this article introduced me to the concept of relationship-based care and the Intentional Relationship Model (IRM), which, to me, more precisely reflects the complex exchange that happens in our work. To me, a relationship is more long term and personal, and is a two-way street.
3. Mental models are incredibly helpful—and this article is a great chance to think about how you view your own relationships with your clients.
I know it feels a little intangible to spend time thinking about how you understand your relationships with various clients. But, I highly recommend thinking about your “mental model” of OT practice. These models give us frameworks for making decisions about complex situations. I was really sold on the importance of mental models when I read the leadership book, Creativity, Inc. (Turns out the leaders at Pixar all have mental models to help them navigate the complex practice of bringing a movie to life.)
After all, if you see yourself in a traditional medical expert role, you are going to make different decisions than if you see yourself as a coach or in partnership or relationship with patients.
I’ll be curious to hear how you think of your own client-therapist relationships!
Here’s the full APA citation for this article:
Babatunde F, MacDermid J, MacIntyre N. Characteristics of therapeutic alliance in musculoskeletal physiotherapy and occupational therapy practice: a scoping review of the literature. BMC Health Serv Res. 2017 May 30;17(1):375. doi: 10.1186/s12913-017-2311-3. Erratum in: BMC Health Serv Res. 2017 Dec 12;17 (1):820. PMID: 28558746; PMCID: PMC5450083.
Earn one hour of continuing education by listening to the podcast on this article!!
In this podcast episode, we dive even deeper into this topic, with OT (and Club member!), Rafi Salazar. You may be eligible for continuing education credit for listening to this podcast. Please read our course page for more details!
