By Tyler Dennthiele, PT
Physical Therapist

“Mrs. Jones, how have your home exercises been going?”

“Well, they are okay. I have done them once or twice in the past few weeks.”

…

This is the start of a conversation nearly all rehabilitation professionals have had in the past with multiple patients. What if I told you that improving the direction of this conversation is up to us as professionals and I had some tips on how to do so?

As rehabilitation professionals, we cannot choose the path of rehabilitation for our patients. They have to choose it for themselves and we act to simply guide them. Many of us would agree that patients who are active participants in goal setting and have specific goals are more motivated to achieve outcomes during a course of therapy than those who may not be able to provide specific goals upon initiation of therapy services.

I hope to show you through this article how we can help patients see the importance of our services and become more active participants in their own goal setting and recovery process.

What Is Therapeutic Alliance?

Therapeutic alliance is defined as “a description of the interaction between the physiotherapist and their patients.” The definition goes on to speak about how the clinician seeks to be seen as a facilitator rather than an authoritarian figure.

When talking about therapeutic alliance, we must turn to the roots of patient-centered care. 20th-century psychologists, including Sigmund Freud, suggested that a strong relationship between patient and provider was a key component to the process of creating change (Kanzer M, 1981). Decades later, this concept is finally becoming mainstream in physical rehabilitation.

Lately, the research around physical therapy and therapeutic alliance has focused on the effects of a strong positive relationship between providers and patients with chronic pain. A systematic review of the topic in 2020 by Kinney et al. states “Emerging evidence suggests that for individuals participating in physical therapy for chronic musculoskeletal pain, a strong TA may improve pain outcomes.” Given this knowledge, How can we improve clinical practice to support a stronger therapeutic alliance with our patients?

Explaining and Asking “Why?” With Your Patients

As rehabilitation professionals, we are often good at telling people what we are going to do for them and how we are going to do it. But as author Simon Sinek suggests in his bestselling book title, we need to transition to starting with why our services, why now. The first step is to speak with our patients, their families, and caregivers and determine their “why”. Instead of asking what goals the patient has, we need to dig deeper and determine why our patients have these goals and why they believe our services are the “what” behind their “why.” This is where education to our patients is typically most appropriate, as many patients may say something to the effect of “Well, my doctor said physical therapy could help.” These conversations may develop over the first couple of weeks with new patients and will work to facilitate the achievement of their personal why.

Early in his book, Sinek states, “leaders with the natural ability to inspire us…have a disproportionate amount of influence in their industries…have the most loyal customers…tend to be more profitable than others in their industry…and they can sustain all of these things over the long term.”

While Sinek was speaking mainly regarding businesses, physical rehabilitation professionals can also approach their interactions with patients as leaders, who inspire greatness in their patients.

Below are some steps that can assist in improving communication skills to become a professional who can effectively interview and inspire your patients to achieve things they once thought impossible. Follow these steps, adapted from ideas from Simon Sinek’s “Start With Why”:

1. Asking Why: Why physical therapy? Why now? Finding ways to ask more “why” questions during our initial interviews, digging deep into the patient (or family members) driving forces behind therapy can build trust by showing your true investment in the person and the achievement of their “why.”
2. Telling Why: To build up the public’s belief in what we do, we need to start with why we do it. Why the interventions we have selected will work and why the patient should trust that we can help them achieve their goals.
3. Positivity in Every Encounter: Remember that conversation I started with? Find a way to turn those conversations into positive encounters. Eliminate all negativity inpatient encounters. Keep in mind your biases and check negativity at the door. Maybe that conversation could look a little something like this:

“Good morning Mrs. Jones! Glad to see you were able to answer the door today!”

“Thank you. To be honest, I haven’t been doing the exercises you asked me to do, but I feel that I am getting better slowly.”

“I understand that it can be a lot sometimes, but I really want to see you get back to being able to play with your grandchildren and get up off the floor. Do you think we could talk about why you have had trouble completing the exercises and adjust the program to better fit your current situation?”

“Yes, I think that would be helpful”

Positivity around our patient’s “why” can go a long way in helping to maintain high levels of trust and engagement in our rehabilitation processes from our patients, which we know can be a catalyst for our patients to achieve their goals. In your first few sessions, really try to dig deep and build trust with your patients and find their true “why,” which may be something they are unwilling to speak about until that trust is built. By starting with “why,” the process will flow more smoothly than ever imagined.

I encourage anyone reading who would like to dive deeper into this concept to check out Start With Why by Simon Sinek—which is where I got the inspiration for this topic.