The Idiot’s Guide to Therapeutic Alliance

*This article is geared toward clinicians and students – however, I think it’s also beneficial for everyone to read. If you’ve ever been, or are ever going to be, a client/patient of a physical therapist, this might tell you what to look for when you’re choosing a provider! 


When I showed up on the first day of my first clinical internship (which just ended!), I was armed and ready. I had a whole page of carefully chosen  goals written down – among them were “gain proficiency in examining and treating the shoulder” (the joint I’d been least comfortable with in our MSK curriculum); “improve my manual therapy skills”; “improve my exercise prescription”; “apply strength and conditioning principles to older adults”; and “consistently perform a thorough and systematic physical examination”.

Those sound like great goals, but what I came to realize over the course of the next 11 weeks was that I really should have written down “make meaningful connections with all of my patients”….and left it at that.

I will give a shout out here to Drs. Mike Reiman, Derek Clewley, Shefali Christopher, and the rest of Duke DPT’s MSK crew for their excellent teaching.  As it turned out, those goals I’d made for myself were things I was anxious about, but….actually pretty proficient in already.  I was already good at deciding which of my patients to put my hands on, and where, and with what techniques.  I was already good at treating shoulders (despite the shoulder being my lowest test score in MSK).  I was already good at choosing interventions, and at progressing them – Actually, I was especially good at this, and I think being a certified strength and conditioning specialist (as well as someone who works out daily, and has coached multiple kinds of athletes) really contributed to that.

Now, there is ALWAYS room for improvement and I’m not going to pretend like I don’t have work to do on my orthopedic skills, but….I came out of our MSK curriculum already pretty solid at orthopedic examination and treatment.  What became apparent very quickly was that I was not very good at simply talking with and connecting with people.

Most PTs will say that the thing they love most about their job is getting to spend so much time with patients.  I saw many of mine for an hour at a time, two times a week….and I can tell you, the value of having that time IS NOT that you get to do more manual therapy, or put them through a longer workout – THE VALUE OF ALL THAT TIME IS THAT YOU GET TO KNOW YOUR PATIENTS AS HUMAN BEINGS.

When you know someone’s personality, when you know what makes them tick, what they’re passionate about, what motivates them, what their barriers are, as well as their children’s names and their dog’s names and why they might not like their boss – it becomes much easier for you to figure out how to help them.  Most importantly, it creates TRUST – when your patients trust you with personal information, they also begin to trust you with their bodies – and when a patient trusts and believes in what you’re doing (whatever that may be, from exercise to dry needling!), then that thing you’re doing tends to work better and your patient benefits more from it.

That trust also allows the patient to explore the psychosocial aspects of their pain or their injury.  Some of them don’t have anyone else to talk to.  I remember when I was going through my first hip labral tear and was unable to participate in any of the sports I loved – no one in my family understood what that was like for me, none of them were willing to entertain my thoughts and fears.  My PT was, though, and that made all the difference.  I had one patient on this first rotation in a similar situation – he’d sustained a severe injury, and was unable to work or do anything he loved all summer long.  He couldn’t talk to his wife or son or boss about it….but he talked with me.  I’ll admit that I made the mistake of trying to push advice on him, trying to get him to look on the bright side…eventually my clinical instructor clued me in (full disclosure, she clued me in multiple times and it took me awhile to get it through my thick skull)  that, really, I just needed to listen to him and let him speak.  Once I did that, he did not, as many of us out there fear, go on forever and ever and ever and perseverate on his anxiety.  He spoke as much as he needed to, and then arrived for his next session feeling upbeat, motivated, and – ready for this? – having done all of his home exercises every single day since we last saw each other. The more I let him speak, the less advice I tried to give (reassurance, yes. advice, no.), the more he began to trust me….the stronger he got….the more CONFIDENT he got….and, boom, he returned to work without pain and with minimal apprehension.

Throughout that first clinical rotation, I was so fixated on ME, on MY skills – MY hands, MY exercise prescription, MY clinical reasoning – that I forgot to pay attention to the human beings in front of me. That’s a huge mistake, and one that I’ll carry with me through the rest of my career.  Pay attention to the person in front of you. Let them speak, let them voice their fears and their anxiety. You have no idea how much these thought processes contribute to patient’s perceptions of their pain and their ability levels.  By building relationships with them, getting to know them, and giving them space to explore their condition – well, I think that’s more important and more powerful than anything we do with our hands or with exercise.  

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