Creating Sustainability With Therapeutic Alliance
As different parts of the world start to come out of isolation and begin pondering what work will look like, we have to acknowledge that things are going to be different…forever.
I’ve seen the question asked “who in this profession is going to make it”?
There was some debate around this and a few comments I’ve seen are things like:
- “massage is a luxury, only those who have money are coming back”
- “Only medical massage therapists will pull through”
- “Only those who work in a clinical setting will be able to recover”
Well, the reality is, none of that is true and it quite frankly doesn’t matter what setting you work in.
This is what determines who will be successful after this pandemic, or any other one we may face down the road.
Using Trust To Create Sustainability
It’s not often I say this, but I have to give some kudos to our college.
While they put in the effort to put together a return to work document1 for our reference and give us some direction on how we should handle things, there was a central point they made in the direction.
Build trust with your patients.
They outlined cleaning procedures, PPE protocols, and new consent instructions, yet at the heart of it all was the direction to do or wear these things in front of your patient, if for no other reason than to build their trust in you as the healthcare professional.
It’s honestly the first time I’ve seen something like this from our regulatory body, and I applaud them for it.
Along with this was a perspective piece written in the New England Journal of Medicine2, although it was written from a doctor’s perspective, I couldn’t help but see how this is applicable to us as therapists.
In the article, they talk about the importance of relying on evidence-based practice. While this is always important, at a time like this that importance is amplified as patients and therapists alike could be making decisions based on fear and emotion, which in turn can result in falling prey to cognitive bias and making therapeutic errors.
Since our role as therapists is to provide safe, effective care we need to have what this article calls a “healthy skepticism” and keep our clinical equipoise when considering any intervention.
If we don’t retain this healthy skepticism we run the risk of relying on personal anecdotes where all too often in our profession we see people saying things like “I know it works because I’ve seen it work” while at the same time refuting and even sometimes refusing to accept research into their practice.
When things like this happen it is usually a result of what the article calls “the intense desire to try new and unproven remedies”. Think about how this applies to many of the continuing education courses we see in our profession. Many of them don’t have research to prove their unsubstantiated claims and yet we look to try this new intervention possibly making therapeutic errors.
Of course, all done with the absolute best of intention trying to help our patients.
If we are going to be successful once this is all over and we want to build sustainability in our practice, this has to change.
As tough as this whole shutdown has been, it has also created an opportunity for change. As we move forward trying to build trust with our patients while also gaining sustainability in this profession, there’s one other golden nugget we need to look at.
There are many things that influence our treatment outcomes that go well beyond whatever our favourite modality is.
Some of these are referred to as non-specific or contextual factors.3
Part of these factors is the therapeutic alliance we have with our patients which can be defined as:
“The working rapport or positive social connection between patient and therapist”3
“Established between therapist and client through collaboration, communication, therapist empathy, and mutual respect”4
This systematic review4 showed there were 8 major themes associated with therapeutic alliance:
- Influencing factors
- Individualized therapy
- Roles and responsibilities
Now, we could probably write an entire article on each one of these 8 themes, how it applies to us in practice, and how we could effectively use them, but let’s leave that for a later date.
For now, let’s just consider what was most important to the patients.
Of those 8 themes the most important determinants of a therapeutic alliance in the eyes of the patient were:
- Interpersonal aspects
- Roles and responsibilities
Another thing the review showed was both patient and therapist agree that effective communication improved treatment adherence. They also found that agreement on goals and tasks, sense of connectedness, positive feedback, genuine interest, individualized care, trust in the therapist, and feeling empowered were all important predictors of exercise or homecare adherence.
The way we communicate, listening, sending appropriate messages and words of encouragement actually has an influence on reduction in pain.4 However, it’s important to note that making inappropriate comments can actually make patient’s symptoms worse (which also demonstrates why communication is so important in the patient’s eyes).
They also came to understand a few more sub-categories important to build this alliance. Included are humour (I can only use a limited supply of this as my sense of humour is pretty offside), emotional intelligence, appreciation, honesty, clarity of information and feedback, support and follow up.
Are you as excited as I am when looking at these lists?
I’m sure most of us are already doing many of these things in our practice, but how often do we practice them, get better at them, take a course on them? While they are deemed “soft skills” the research is showing us these things should be at the forefront of our practice.
And the great thing…we get to spend more time with our patients than most other manual therapists and we can literally practice most of these things during our treatments. This was another one of the things that positively influenced outcomes, the amount of time spent with the patient along with warm, empathic interaction!4 So while there was no way for us to predict this pandemic, there are ways for us to create sustainability in our career. Massage therapy as a profession isn’t going anywhere, people will still need help, and still want to be touched in a therapeutic way. Unfortunately, some clinics won’t recover from this which is an absolute travesty that no one deserved to go through. But the best way to create sustainability is by enhancing and developing strong therapeutic relationships with our patients. With that strong relationship, should something like this ever happen again, those patients will be waiting for your clinic doors to open again because they trust you will do what’s best for them. As we start our clinics up again, while it won’t be the same, there is a genuine opportunity to start building that trust again while creating sustainability in your practice.
- Zagury-Orly I, Schwartzstein RM. Covid-19—A Reminder to Reason. New England Journal of Medicine. 2020 Apr 28
- Fuentes J, Armijo-Olivo S, Funabashi M, Miciak M, Dick B, Warren S, Rashiq S, Magee DJ, Gross DP. Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: an experimental controlled study. Physical therapy. 2014 Apr 1;94(4):477-89.
- 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 services research. 2017 Dec;17(1):375.
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Great article, thank you, Jamie Johnston.
Thanks, Carole glad you enjoyed it.