The term therapeutic alliance has gained significant attention recently as the U.S. healthcare system gradually shifts toward a value-based payment model. It is becoming increasingly clear that achieving positive patient outcomes extends beyond clinical procedures—engaging patients in their own health journey is essential. Whether in rehabilitation or general health management, fostering a strong patient-provider relationship is fundamental to success.

For physical therapists, the primary goal is often seen as helping patients recover from or prevent injuries. However, a successful clinical outcome is not solely dependent on what is done to the patient but also on how the patient actively participates in their recovery.

The Role of Therapeutic Alliance in Patient Success

Consider this example: A physical therapist can perform the perfect mobilization technique on a patient’s lumbar spine and prescribe highly effective exercises. However, if the patient does not apply these benefits outside of the clinic, the likelihood of success significantly decreases.

So, how can therapists encourage patient participation? The reality is that we cannot force patients to engage in their own recovery; rather, we must help them choose to get better. Achieving this level of influence is what we call Jedi-level physical therapy.

The concept of therapeutic alliance provides a valuable framework for this process. Originally rooted in psychology, this concept traces back to Sigmund Freud’s theory of transference, where unconscious redirection of feelings occurs between the patient and therapist. Later, Carl Rogers, the father of client-centered therapy, outlined three core components of a strong therapeutic alliance:

• Empathy

• Congruence

• Unconditional positive regard

Psychologists have long recognized that the strength of the patient-provider alliance is a key factor in treatment success [1]. Edward Bordin expanded on this by emphasizing that the strength, rather than the type, of the alliance is what truly influences outcomes [2]. This principle applies across various relationships, including student-teacher, employee-manager, and, of course, patient-provider interactions.

While physical therapy encompasses various techniques—taping, needling, and manual therapy—none of these interventions can fully explain patient outcomes. The therapeutic alliance provides the necessary context for these techniques to be effective. Without it, the essential element of patient engagement is missing.

Three Steps to Achieve a Strong Therapeutic Alliance

1. Establish Shared Treatment Goals

   • A shared understanding of goals between therapist and patient is crucial. Misalignment can hinder progress, whether the patient’s goals are unrealistic or they are capable of more than they believe.

   • Establishing alignment requires exploring the patient’s motivations and beliefs. If their expectations conflict with reality, the therapist must skillfully guide them toward achievable and meaningful objectives.

2. Align on the Treatment Pathway

   • A key question to ask patients: “What do you think will be required to achieve these goals?”

   • This question reveals the patient’s perspective on their role and expectations of the therapist, helping bridge any gaps in perception.

   • Effective communication, active listening, and observational skills are critical to ensuring alignment on the required steps.

3. Demonstrate Unconditional Positive Regard

   • Maintaining a positive and non-judgmental attitude toward patients can be challenging, especially when personal biases or frustrations arise.

   • Recognizing these biases and managing them appropriately is essential to fostering a strong therapeutic connection.

   • Even when dealing with difficult patients, approaching interactions with empathy and respect improves engagement and outcomes.

The Future of Patient Engagement in Physical Therapy

As healthcare shifts toward value-based care, engaging patients in their own health will be a defining factor for success. A strong therapeutic alliance—built on shared goals, agreement on the treatment process, and unconditional positive regard—will distinguish effective physical therapists from the rest. Mastering these principles will lead to better outcomes for both patients and providers, ensuring that therapy is not just something done to patients but a collaborative effort toward lasting health improvements.

Are you ready to strengthen your therapeutic alliance and improve patient outcomes? Start by implementing these three steps in your practice today. Learn more about how to improve patient outcomes by taking the course! Have you found strategies that work particularly well? Connect with us to continue the conversation!

1. Horvath A. O., Luborsky L. (1993). The role of the therapeutic alliance in psychotherapy. J. Consult. Clin. Psychol. 61, 561–57310.1037/0022-006X.61.4.561 [PubMed] [CrossRef] [Google Scholar]
2. Rogers C. R. (1951). Client-Centered Therapy. Boston: Houghton Mifflin [Google Scholar] [Ref list]
3. Ardito, R. B., & Rabellino, D. (2011). Therapeutic alliance and outcome of psychotherapy: historical excursus, measurements, and prospects for research. Frontiers in psychology, 2, 270. doi:10.3389/fpsyg.2011.00270
4. Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16(3), 252–260. doi:10.1037/h0085885