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Within physiotherapy, the bond between a patient and their therapist is recognised as being hugely important in allowing effective recovery from injury.

A positive therapeutic alliance ensures patients are satisfied with the input they receive and it’s even suggested this may directly influence treatment outcomes (1).

However, while it is recognised that an effective patient-therapist bond is essential in physiotherapy’s ‘Codes of Conduct’ (2)(3), the way in which these relationships are developed and maintained are much less obvious.

This blog will look at what constitutes an effective therapeutic alliance within physiotherapy and discuss what effects this may have upon our patients and their outcomes.


What is a ‘therapeutic alliance’?

Therapeutic alliance is a term given to the relationship between any healthcare professional and a patient who is under their care.

This relationship is predominantly based around the way in which each party engages with the other to result in a beneficial change to the client, and is regarded as a crucial factor in achieving positive results.

Historically, Sigmund Freud first referenced the beneficial effects of positive working alliances in 1912, before widely referenced work by Bordin in the 1970’s began to theorise the factors required to obtain such relationships.

He proposed that these bonds consisted of:

  • Goals – what are the aims of the proposed treatment?
  • Tasks – what do we need to do to achieve the above?
  • Bond – establishing a trustful relationship to pursue the above

More recent research suggests that these factors can have a significant effect upon a patients perception of the quality of their care (4) as well as directly influencing the outcomes of their treatment (1).

Whilst originally, this work was developed within a psychoanalytic field, the obvious benefits of positive therapeutic alliances have become widely appreciated within all forms of healthcare, including physiotherapy.

Why might this be important within physiotherapy?

It makes sense!

When considering the attributes required to be a competent physio, it becomes clear that these factors are essentially our entire skillset:

Job Description: Physiotherapist We are looking for an appropriately qualified physiotherapist to join our team. The successful applicant will: Be able to encourage patients to disclose substantial information in order to diagnose their issues, provide appropriate explanations and identify how any problems can be addressed (ie ‘goals’!) Be able to formulate suitable ways of addressing issues to gain an improvement in symptoms using a variety of treatment methods that are individually tailored and agreed to by the patient (ie ‘tasks’!) Carry out both of the above with a high level of trust within both parties. This involves clients trusting the therapist’s aptitude to successfully diagnose and provide suitable advice, and therapist being able to trust patients to follow the agreed treatment plan (ie ‘bond’!)


When considering the above, it may be argued that within physiotherapy a decent working relationship is more essential to a successful recovery than many other areas of healthcare.

For our patients to get better they often need to undertake a specific set of exercises, at a certain frequency and often adhered to for a sustained length of time. This differs from many forms of input (think pharmacology, radiography/imaging, passive therapies etc)- in which a method of input may be administered in a more simple ‘dosage’, with its effects often obtained quicker and with arguably less ‘buy in’ required by patients.

As a result, it is easy to see the importance of establishing an effective bond, that is sustained for the entire duration of the rehabilitation process, in order to provide confidence that goals can be achieved with the help of physiotherapy.

In short– physio’s have the ability to develop relationships that may not be awarded to other healthcare professionals due to us seeing patients for longer durations and for more sustained periods of time… and these alliances are essential for achieving positive results .

How easy is this to achieve?

While it may be possible to ‘teach’ therapists how to communicate effectively in order to help establish effective working relationships, it is accepted that human interaction is a highly complex topic.

Generally speaking, communication consists of an intricate mixture of:

  • Verbal exchanges
  • Written or pictorial information
  • Non-verbal factors (such as posture, facial expressions and general bodily orientation).

Within physiotherapy, significant amounts of pre-graduate training is normally awarded to developing written communication skills (I am thinking of the significant amount of essays, dissertations and ‘SOAP Notes’ training that we had to undertake!), in which demonstrating your knowledge is predominantly achieved by a collection of largely written pieces of work.

When considering the aforementioned factors that are required to perform the role as a physiotherapist successfully, it may be questioned whether we are suitably prepared for these crucial aspects of the job.

This is highlighted by a 2010 research study, in which a cohort of physiotherapy students were asked to rate their readiness for communicating during employment interviews and then certain clinical scenarios if successfully obtaining employment. Results showed that participants were almost unanimous in believing that they weren’t suitably equipped with the array of communication skills required to make the transition from student to practicing therapist (5).

Furthermore, while communication remains the paramount ‘pillar’ of our professional guidelines as a physio (2) (3), with widely recognised appreciation of the consequences of a breakdown in the exchange of information within healthcare (6), it may be argued that development of some interaction skills still remain an individual process requiring significant amounts of experience to perfect.

But can you actually ‘teach’ communication?

In a word- yes!

Whilst it is recognised that some people may find it easier to apply and adapt communication than others, it is evident there is a number of cue’s that can easily be adopted to assist the development of a positive patient-therapist relationship.

Firstly, this requires an understanding of the different components that are involved in successful communication… these factors are likely to involve verbal, non-verbal and potentially written/pictorial forms of communication, which will differ depending upon the setting that you work in and the patients that you encounter.

Whilst communication is a complex topic, it is evident that certain non-complicated methods may be used from the very first encounter with a patient… which can result in favourable outcomes in their rehabilitation (1)(7)(8).

How might this be achieved?

Research indicates that positive working relationships can be assisted by:


  1. Allowing the time for a patient to explain their issues and tell their ‘story’
  2. Demonstration of therapist confidence and aptitude… whilst explaining issues in translatable language
  3. Displaying empathy, understanding and concern
  4. Accurately demonstrating ongoing progress with rehabilitation

(Kidd et al, 2011)


  1. Demonstrations of ‘active listening’ (reduced note taking and increased eye gaze)
  2. High levels of eye contact
  3. Avoidance of ‘closed body language’
  4. Direct body orientation (ie sitting face to face with patients without obstacles)

(Kidd et al, 2011; Pinto et al, 2012)


  1. Establishing a positive initial impression (ie clean and tidy appearance/environment, use of preferred name/title, outlining premise of initial encounter and physiotherapy as a whole)
  2. Providing a clearly explained diagnosis where able
  3. Joint decision making regarding treatment methods
  4. Avoidance of negative explanations or general demeanour
  5. Keeping of ‘promises’ (ie be accurate with predictions/timeframes for recovery, avoid lateness, if you say you will send out exercises then do it!)

(Bordin, 1979; Kidd et al, 2011)

Why might this have a positive effect?

Within physiotherapy, it should be appreciated that our treatments can often involve more active application than medical or surgical disciplines, in which medication and/or invasive input can usually be received by users with lower levels of participation and commitment.

Our patients are usually required to:

  • Complete a series of specific exercises in a specifically-delivered way, at a desired ‘dosage’ of sets, repetitions and amount of intensity
  • Carry out the above exercises with regularity within their (precious!) free time
  • Adhere to specific advice to avoid any aggravation of their issues
  • Usually continue the above for a significant duration of time to allow improvements to be made and to prevent reoccurrence of injury

When considering these factors it seems obvious that a positive alliance is likely to increase patient participation, enhance levels of satisfaction with the care they have received and therefore achieve more favourable treatment outcomes.

This is reflected in a 2012 study (1) in which a group of patients with chronic lower back pain were asked to rate their working relationships with their physiotherapists throughout a course of treatment, before recording the amount of improvement shown following their input.

Patients who had deemed they had a positive alliance with their therapist reported significantly enhanced global improvements in their issues… regardless of the specific type of treatment that they received.

This is further reinforced by studies in alternative physiotherapy settings, such as cardiac rehabilitation (9) and acute brain injuries (10), in which functional improvements are increased with increased levels of therapeutic alliance, when compared to counterparts who rate their working relationships with lower satisfaction.

These findings help to reiterate the beneficial results of effective communication within physiotherapy and demonstrate why its importance remains at the centre of many of our healthcare experiences.

So to summarise…

It has been widely recognised for a number of years that a positive working relationship between a patient and their therapist is paramount to achieving successful results across many forms of healthcare. However, human interaction is a highly complex topic that is difficult to measure objectively, therefore using effective communication within clinical situations may be a difficult process without having an understanding of the components involved.

Developing communication skills has traditionally remained an individual process for therapists, that generally becomes easier with ‘patient mileage’ and exposure to a variety of situations, with research suggesting that novice therapists can often feel ill-equipped with the necessary tools to achieve this initially.

However, whilst it is appreciated that the art of interaction will continue to evolve with experience, it is evident that a number of communicative ‘cues’ may be incorporated into a variety of clinical encounters with positive effects.

These often-simple factors remain the main criteria cited by patients as being important to them during clinical interactions, therefore possessing an awareness of these communicative requirements may allow effective relationships to be established, thus allowing successful results to be achieved.


1)     Ferreira, P., Ferreira, M., Maher, C., Refshauge, K., Latimer, J. and Adams, R. (2012). The Therapeutic Alliance Between Clinicians and Patients Predicts Outcome in Chronic Low Back Pain. Physical Therapy, 93(4), pp.470-478.

2)     HCPC (2019). Standards of conduct, performance and ethics. [online] Available at: https://www.hcpc-uk.org/standards/standards-of-conduct-performance-and-ethics/ [Accessed 5 Feb. 2019]

3)     CSP (2019). Code of Members’ Professional Values and Behaviour. [online] Available at: https://www.csp.org.uk/publications/code-members-professional-values-and-behaviour [Accessed 5 Feb. 2019].

4)     Pinto, R., Ferreira, M., Oliveira, V., Franco, M., Adams, R., Maher, C. and Ferreira, P. (2012). Patient-centred communication is associated with positive therapeutic alliance: a systematic review. Journal of Physiotherapy, 58(2), pp.77-87.

5)     Jones, M., McIntyre, J. and Naylor, S. (2010). Are physiotherapy students adequately prepared to successfully gain employment?. Physiotherapy, 96(2), pp.169-175.

6)     Final report of the independent inquiry into care provided by Mid-Staffordshire NHS Foundation Trust published (UK). (2013). Leadership in Health Services, 26(2).

7)     Kidd, M., Bond, C. and Bell, M. (2011). Patients’ perspectives of patient-centredness as important in musculoskeletal physiotherapy interactions: a qualitative study. Physiotherapy, 97(2), pp.154-162.

8)     Hall, A., Ferreira, P., Maher, C., Latimer, J. and Ferreira, M. (2010). The Influence of the Therapist-Patient Relationship on Treatment Outcome in Physical Rehabilitation: A Systematic Review. Physical Therapy, 90(8), pp.1099-1110.

9)     Burns, J. and Evon, D. (2007). Common and specific process factors in cardiac rehabilitation: Independent and interactive effects of the working alliance and self-efficacy. Health Psychology, 26(6), pp.684-692.

Burns, J. and Evon, D. (2007). Common and specific process factors in cardiac rehabilitation: Independent and interactive effects of the working alliance and self-efficacy. Health Psychology, 26(6), pp.684-692. Scho¨nberger M, Humle F, Teasdale TW.

The relationship between clients’ cogni-tive functioning and the therapeutic working alliance in post-acute brain injury reha-bilitation. Brain Inj. 2007;21:825–836chönberger, M., Humle, F. and Teasdale, T. (2007). The relationship between clients’ cognitive functioning and the therapeutic working alliance in post-acute brain injury rehabilitation. Brain Injury, 21(8), pp.825-836.

10)     Schönberger, M., Humle, F. and Teasdale, T. (2007). The relationship between clients’ cognitive functioning and the therapeutic working alliance in post-acute brain injury rehabilitation. Brain Injury, 21(8), pp.825-836.

11)     Bordin, E. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16(3), pp.252-260.

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