Social support from the physiotherapist and the therapeutic relationship in physiotherapy: bridging theory to practice

ABSTRACT

Background/Purpose

Therapeutic relationship and social support are critical components in physiotherapy that shape patient outcomes. However, defining these constructs, discerning their similarities and differences, and measuring them pose challenges. This article aims to facilitate scientific and clinical advancement on social support and the therapeutic relationship in physiotherapy by (a) providing conceptual clarity, (b) discussing measurement tools, and (c) offering practical recommendations for the deliberate incorporation of these constructs in clinical practice.

Methods

This is a perspective paper drawing on examples from existing research.

Key Results

Assessing the nature and strength of social support and promoting naturally occurring social support networks are practical ways for physiotherapists to foster social support in physiotherapy clinical practice. Physiotherapists can offer direct support, facilitate the development of an individual’s social skills, and promote participation in group activities. To strengthen the therapeutic relationship, it is important to maintain good communication, foster connectedness with the patient, demonstrate professional skills, and adopt a reflective practice. Physiotherapists are encouraged to establish clear roles and responsibilities, prioritize individualized patient-centered care, and involve patients in shared decision-making, ensuring congruence in goals and expectations. Willingness to dedicate time and energy within and beyond direct patient-therapist interactions can foster connections. Moreover, using the body – which is the main point of contact with patients – and physical touch can help physiotherapists to connect with patients. Finally, physiotherapists must be prepared to address and mend any conflicts which can impact the relationship’s trajectory.

Conclusion

Social support and therapeutic relationships are complementary aspects of one’s health care, and it is crucial to purposefully account for both in physiotherapy practice to optimize person-centered care and rehabilitation outcomes.

KEYWORDS:

• Therapeutic relationship
• social support
• social relationships
• rehabilitation
• physiotherapy

Introduction

Strong social relationships help humans navigate stressors, resolve problems, and overcome challenges (Holt-Lunstad, Smith, Layton, and Brayne, 2010). The development of relationships is identified as a core element of quality healthcare (Molina-Mula and Gallo-Estrada, 2020). However, understanding and assessing the factors that influence these relationships—particularly in physiotherapy—is an evolving process that warrants focused discussion.

Social support is a critical component of the biopsychosocial model, which is widely promoted in the physiotherapy context (Engel, 1977). This model emphasizes the importance of taking a holistic approach to healthcare; recognizing that health outcomes cannot be solely attributed to biological factors, but instead result from psychological and social factors such as social networks, socioeconomic status, and cultural context (Engel, 1977). Social support can also be situated within the International Classification of Functioning, Disability, and Health (ICF) framework as an important environmental factor. This influences an individual’s functioning by encompassing the availability of assistance, encouragement, and relationships, which can either facilitate or hinder their ability to participate in various life situations (World Health Organization, 2007). This support gains particular significance in the context of health conditions, where the social support provided by the physiotherapist can significantly impact disease progression, management, and outcomes (Chronister, Chou, Frain, and da Silva Cardoso, 2008).

As these models became more widely used in physiotherapy, it has led to a shift toward more person-centered care (PCC). PCC is “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions” (Richardson et al., 2001, p. 6), and is acknowledged by several disciplines as being a standard of quality in clinical practice (Sidani and Fox, 2014). Social support has been identified by patients as a main dimension of PCC (Gerteis et al., 1993), with one of the key ways to promote PCC being through strong therapeutic relationships (Légaré et al., 2010; Mead and Bower, 2000; Morgan and Yoder, 2012).

There is a growing recognition of the importance of the therapeutic relationship in the field of physiotherapy (Hall et al., 2010; Morera-Balaguer et al., 2018), and recent efforts have been made to develop high-quality, discipline-specific measures of physiotherapy therapeutic relationships (McCabe et al., 2021). Similar to social support, the subjective nature of these theoretical constructs or phenomena can make it challenging to directly observe, measure, and improve them (Greenhalgh and Heath, 2010). In addition, there has been some divergence as to whether healthcare providers can be considered sources of social support, and a lack of clarity regarding the similarities and differences between social support provided by the healthcare provider and the therapeutic relationship (Cohen, 2004; Lauzier-Jobin and Houle, 2022; Leibert, Smith, and Agaskar, 2011). Evidence suggests that we should be going beyond tacit knowledge to more deliberately think about ways to effectively deliver social support and strengthen the therapeutic relationship (Cohen, 2004). Therefore, there is a need for physiotherapists to build on the available and growing body of evidence to explicitly incorporate these constructs into their clinical practice.

The purpose of this perspective paper is to prompt physiotherapists from all areas to intentionally reflect on social support and therapeutic relationships in their clinical practice. The authors provide a review of concepts, discuss the main available measurement tools, and offer practical recommendations to support physiotherapists in optimizing their interventions to ensure patients achieve their full rehabilitation potential.

Definition, history, and models of social support

Social support is a multidimensional and interactive process (Barrera, 1986; Lakey and Drew, 1997; Sarason, Pierce, and Sarason, 1990). A commonly acknowledged definition of social support is “a social network providing psychological and material resources to benefit an individual’s ability to cope with stress” (Cohen, 2004, p.676). Expanding on this, social support encompasses any process through which social relationships might promote health and well-being (Cohen, 2004). Emotionally, it can provide a buffer against the emotional challenges associated with physical health issues (Cohen and Wills, 1985). Psychologically, support from others can shape thoughts and beliefs about health and disability (Cohen and Wills, 1985). Behaviorally, it can impact adherence to physiotherapy and promote positive lifestyle changes (Cohen and Wills, 1985). This highlights the broader relevance of social support to physiotherapy. Social support can be informal help from an individual’s close network (i.e., family and friends), or it can be a more formal, structured, and deliberate help offered by healthcare professionals. This paper focuses on the latter.

Research about social support emerged in the mid-1970s, exploring how psychosocial factors influence mental and psychological health (Caplan, 1974; Cassel, 1974; Cobb, 1976). Cohen and Wills (1985) proposed two influential models: (1) the buffering model, where social ties protect against stress, and (2) the main effect model, where social resources benefit well-being regardless of stress levels.

Social support involves four main types of resources (Table S1): emotional, informational, instrumental, and social companionship (Cohen, 2004; Cohen and Wills, 1985). It is often categorized into three broader aspects: social embeddedness (presence of connections in one’s environment), enacted support (actions taken to support others), and perceived social support (the cognitive appraisal of reliable connections) (Barrera, 1986).

Considering that the focus of this paper is on the social support provided by the physiotherapist, how can knowledge of social support, with its many categorizations, help physiotherapists in the care of their patients? Consider this example: a middle-aged woman recovering from knee surgery. She experiences pain, frustration, and anxiety about her recovery. Upon assessment of the patient’s social support system, the physiotherapist learned that her boyfriend provides emotional support but doesn’t fully understand her physical challenges. Her closest friend, who had a similar knee surgery, offers advice and shares her experiences. Her brother helps with household chores. She has a close-knit group of friends with whom she used to enjoy recreational activities, but she has distanced herself from them since her surgery. Understanding these different facets of social support, the physiotherapist can provide more effective care in the following ways:

1. Emotional Support: Provide empathy and encouragement during therapy sessions, helping her cope psychologically; involve her boyfriend to help him understand her situation better.

2. Informational Support: Encourage advice from her best friend while also ensuring she receives accurate information about her recovery and rehabilitation process.

3. Instrumental Support: Collaborate with her brother to ensure that the patient’s home environment is conducive to her recovery.

4. Social Companionship: Recognizing the isolation from her social group, the physiotherapist can work with her to set realistic goals for returning to her recreational activities. They could also encourage participation in new peer support groups of people dealing with the same condition.

By considering these different aspects of social support and tailoring their care accordingly, the physiotherapist can address not only the physical but also the emotional and social components of the patient’s recovery. This enhances the likelihood of successful rehabilitation and a more positive overall patient experience. This example emphasizes the importance of immediate relationships (which is the emphasis of this paper), but social support is a complex construct that could encompass many other factors, such as the role of the employer, the workplace, the funding provider, and society.

The therapeutic relationship

Some theoretical definitions exclude healthcare professionals as sources of social support (Cohen, 2004), and some refer to this formal helping relationship as the therapeutic relationship (Lauzier-Jobin and Houle, 2022; Leibert, Smith, and Agaskar, 2011). In fact, these are essentially distinct constructs, as the following paragraphs will show. However, both involve interpersonal connections that contribute to helping individuals to problem-solve, cope with stress, and navigate life’s challenges. Therefore, some capacities of the therapeutic relationship mirror inherent aspects of perceived social support, such as emotional bonds, mutual trust, and an appraisal of supportiveness (Kuentzel, 2000).

The therapeutic relationship, also referred to as rapport (Cole and McLean, 2003) or therapeutic alliance (Henry and Strupp, 1994), derives from theories of transference first outlined by Freud (1958) and conceptualized by Bordin (1979) as the degree to which the therapy pair is engaged in collaborative, purposive work. The therapeutic alliance comprises three domains: (1) the therapist-patient agreement on the goals of treatment, (2) the therapist-patient agreement on interventions, and (3) the affective bond, which refers to mutual trust and feelings of being understood and respected (Bordin, 1979). While the therapeutic alliance primarily focuses on the working collaboration between patient and provider, the therapeutic relationship considers a greater depth of the personal connection. It encompasses all aspects established by the patient and therapist as ways of connecting and moving toward treatment goals during clinical encounters (Miciak et al., 2018). An accepted definition of the therapeutic relationship is “a trusting connection and rapport established between therapist and patient through collaboration, communication, therapist empathy and mutual understanding and respect” (Cole and McLean, 2003, p. 33).

Throughout the 20^th century, nursing theorists like Peplau (1952) made significant contributions to the understanding of the therapeutic relationship in nursing practice (Peplau, 1952). In rehabilitation, Kayes et al. (2016) developed a conceptual framework highlighting: the importance of forming personal connections; showing your knowledge as a practitioner, valuing patients and their contributions; and being a professional to patients (Kayes and McPherson, 2012; Kayes et al., 2016; Kayes, McPherson, and Kersten, 2015). In physiotherapy, the core components of the therapeutic relationship include patient expectations, personalized therapy, partnership, physiotherapist roles and responsibilities, congruence, communication, relational aspects, and influencing factors (Besley and McPherson, 2011). Miciak et al. (2019) identified ways to connect with patients in physiotherapy—therapeutic touch being one of them—which is a key difference in physiotherapy therapeutic relationships compared to psychotherapy. Using the body as a pivot point in physiotherapy practice means supporting patients to become aware of and (re)connect to their own bodies, clarifying physical problems and solutions, as well as using physical touch as a vehicle for establishing meaningful connections (Miciak et al., 2019).

Few studies have addressed the relationship of both perceived social support and therapeutic relationships on treatment outcomes. Mallinckrodt (1996) suggested that both constructs are connected rather than independent in their influence on outcomes. Lambert’s (1992) model observed additive impacts on outcomes. In two more recent articles, both constructs predicted a positive health outcome; however, a good therapeutic alliance was particularly relevant for patients with poor social support (Leibert, Smith, and Agaskar, 2011; Zimmermann et al., 2021). All these authors conceptualized social support as “extra-therapeutic,” often measured before psychotherapy, and they focused on the therapeutic alliance rather than the therapeutic relationship.

While health professionals can provide emotional and informational support, other types of social support, such as instrumental or companionship support, usually require more intimacy and are unlikely to be effectively provided within a professional therapeutic context. The power imbalance and professional boundaries of a therapeutic relationship will likely prevent that from happening; therefore, it is important to consider other sources of social support external to the clinical interaction in physiotherapy practice.

Overall, both are distinct but complementary aspects of one’s health care, predicting mental and physical health outcomes. While healthcare professionals are integral to the social network of people in the treatment of any health condition, offering social support is just one aspect of the nuanced and complex relationships between patients and healthcare providers. On the other hand, strong therapeutic relationships characterized by trust, empathy, and collaboration are the foundation for the provision of social support from healthcare providers. This interconnectedness motivates the discussion of both these constructs in this paper.

Measurement tools for social support and the therapeutic relationship

Although there is inherent subjectivity tied to the concepts being explored, operationalizing and measuring social support and the therapeutic relationship is vital to advance research and clinical practice in this area.

As social support and therapeutic relationships are different constructs, the available instruments to evaluate them are also distinct. Numerous assessment tools have been proposed in the past decades to assess social support, which vary in length, focus, and approach (Gottlieb and Bergen, 2010; Heitzmann and Kaplan, 1988). This can impair clinicians’ abilities to draw conclusions, synthesize, and compare the results of research studies meant to investigate the relationship between social support and health outcomes (Sarason, Pierce, and Sarason, 1990). Diversity in the literature is something to be appreciated; however, it requires clinicians to carefully identify the social support domains that they wish to assess according to their patients’ priorities and the measurement tools that fit this purpose.

Social support can be objectively measured by observable variables like the number of people in the household or the number of interactions with family and friends over a period of time (Leibert, Smith, and Agaskar, 2011), nonetheless objective measures do not illuminate the mechanisms through which these relationships may improve health outcomes (Leibert, Smith, and Agaskar, 2011). Subjective measures, based on individuals’ feelings of support and connection, are often self-reported and assess specific functions of relationships – such as perceived availability and adequacy (Cohen and Wills, 1985). Table S2 in the Supplementary Materials provides detailed information on social support instruments.

The Working Alliance Inventory (WAI) has been frequently used to measure the therapeutic relationship in rehabilitation studies (Horvath and Greenberg, 1989). Its Dutch version has been recently validated for rehabilitation (Paap, Schrier, and Dijkstra, 2019), and the Pain Rehabilitation Expectations – Working Alliance Subscale was validated for people with chronic back pain (Cheing, Lai, Vong, and Chan, 2010). However, the WAI may not fully capture all aspects of the therapeutic relationship, particularly regarding connection through the body (i.e., physical touch or physical assessments), which is critical in physiotherapy (Miciak et al., 2019). Newer tools like the Person-Centered Therapeutic Relationship in Physiotherapy scale (PCTR-PT) (Rodríguez Nogueira et al., 2020) offer comprehensive domains for assessing therapeutic relationships in physiotherapy. Other tools, such as the “Communication Preferences of Patients with Chronic Illness” (KOPRA questionnaire) (Farin, Gramm, and Schmidt, 2012) and the “Consultation and Relational Empathy” (CARE) measure (Mercer, Maxwell, Heaney, and Watt, 2004), focus on specific aspects of the therapeutic relationship, such as communication preferences and relational empathy. Finally, the Physiotherapy Therapeutic Relationship Measure (p-TREM) is another tool specific to measuring therapeutic relationships in physiotherapy, which addresses the need for validated instruments tailored to this field (McCabe et al., 2021, 2022).

Most existing tools focus on patients’ self-assessments of social support and therapeutic relationships, as these evaluations better predict treatment effectiveness compared to therapists’ ratings (Kuentzel, 2000; Martin, Garske, and Davis, 2000). This aligns with the conceptual framework of PCC, which is directed toward the holistic and individualized care of people, in which the person is empowered to participate in health decisions and reflect on the quality of care they receive (Rodríguez Nogueira et al., 2020).

The relationship between social support and the therapeutic relationship with rehabilitation outcomes

Social support and rehabilitation outcomes

Social support has been discussed as an integral component of treatment planning and intervention in rehabilitation (Chronister, Johnson, and Berven, 2006). There is a large body of evidence consistently supporting a positive association between social support and rehabilitation-related outcomes, such as adjustment to disability (Hatchett, Friend, Symister, and Wadhwa, 1997; Holosko and Huege, 1989; McColl and Rosenthal, 1994; Schulz and Decker, 1985); quality of life (McColl and Rosenthal, 1994; Rintala et al., 1992; Schulz and Decker, 1985; van Leeuwen et al., 2010); employment (Anderson and Vogel, 2002; Belgrave and Walker, 1991); psychological health (mainly referring to fewer depressive symptoms)(Anderson and Vogel, 2002; McColl and Rosenthal, 1994; Rintala et al., 1992; Symister and Friend, 2003) and treatment compliance (Anderson, Deshaies, and Jobin, 1996; Lewin, Jöbges, and Werheid, 2013) among persons with disabilities and chronic illness. Diagnoses in these studies were spinal cord injury, head injury, amputation, coronary artery disease, stroke, and chronic obstructive pulmonary disease (COPD). Some studies outlined that they evaluated social support from both family and medical staff (Hatchett, Friend, Symister, and Wadhwa, 1997). However, the vast majority were not clear about who provided the support being assessed.

To date, Chronister, Chou, Frain, and da Silva Cardoso (2008) wrote the only published systematic review investigating the relationship between social support and rehabilitation-related outcomes. For the meta-analysis, 26 studies were included (n = 4,842), and the authors divided the different types of functional support into perceived availability, perceived satisfaction, and received supportive behaviors (Chronister, Chou, Frain, and da Silva Cardoso, 2008). The outcome measures were combined into five categories: physical health, psychological health, quality of life, adjustment to disability, and employment status (Chronister, Chou, Frain, and da Silva Cardoso, 2008). Findings suggested that those who perceive the availability of support may experience better physical outcomes and adjustment to the disease. This is especially relevant for rehabilitation appraisal and design, as adjusting to disability/chronic illness is a primary goal in service delivery (Chronister, Chou, Frain, and da Silva Cardoso, 2008).

Therapeutic relationships and rehabilitation outcomes

Despite the growing interest in understanding how patient-provider relational elements influence patients’ experiences of care and outcomes, there are few systematic reviews investigating the influence of the therapeutic relationship on treatment outcomes in physical rehabilitation (Hall et al., 2010; Kinney et al., 2020; Lakke and Meerman, 2016; Taccolini Manzoni, Bastos de Oliveira, Nunes Cabral, and Aquaroni Ricci, 2018). Hall et al. (2010) included 13 studies in their review, which demonstrated a positive association between the therapeutic alliance and rehabilitation-related outcomes, such as: treatment adherence and satisfaction (Beattie et al., 2005; Schönberger, Humle, Zeeman, and Teasdale, 2006); depressive symptoms (Mirsky, 2002); and physical function (Ferreira et al., 2013; Higdon, 1997). Despite this, Hall et al.’s review was not sufficiently homogeneous to allow a meta-analysis. The patient population’s diagnoses in the included studies were brain injury, musculoskeletal conditions, cardiac conditions, and multiple pathologies such as systemic diseases, trauma, post-operative conditions, and chronic pain (Hall et al., 2010). It is important to clarify that Hall et al.’s (2010) review focused on the therapeutic alliance, which is a broader concept than the therapeutic relationship.

The other three reviews focused on the impact of the therapeutic alliance on pain outcomes for individuals with musculoskeletal pain undergoing physiotherapy. Lakke and Meerman (2016) found that the therapeutic alliance did not predict pain reduction and improvement in physical functioning. Corroborating these findings, Taccolini Manzoni, Bastos de Oliveira, Nunes Cabral, and Aquaroni Ricci (2018) also showed that the available studies failed to provide evidence of a strong relationship between the therapeutic alliance and pain outcomes. Conversely, Kinney et al. (2020) demonstrated that emerging evidence suggests that a strong therapeutic alliance may improve pain outcomes.

How to consider social support and the therapeutic relationship in physiotherapy practice?

Assessing the strength of social support and therapeutic relationships can be complex and challenging. Reasons for this include: (1) the subjective and qualitative nature of these constructs, which involve emotions, perceptions, and interpersonal dynamics, making them challenging to quantify accurately; (2) the diversity of measurement tools, many facing fundamental problems concerning the validity and theoretical framework (Paap et al., 2022); (3) ethical considerations, as some may argue that quantifying this relationship might oversimplify a complex and deeply personal process, potentially impacting the therapeutic relationship and resulting in an overestimation of the therapist’s capacity. Still, as research in physiotherapy evolves and high-quality measures of social support and therapeutic relationships begin to be developed and validated (McCabe et al., 2022; Rodríguez-Nogueira et al., 2020), we suggest the assessment of both to be incorporated into physiotherapy clinical practice, as both are potentially modifiable and can contribute to the individual reaching their full rehabilitation potential. Understanding and promoting communication about the patient’s social context, interpersonal relationships, family roles, and leisure preferences is essential to effectively foster social support through physiotherapy (Benzo, 2017).

Taking into consideration what is known from existing research on the role of social relationships in health and well-being in physiotherapy clinical practice, it is recommended to emphasize patients’naturally occurring social networks (Cohen, 2004). This presents an opportunity to potentially foster enduring changes in relationships that can serve as a reliable source of support beyond the active intervention period (Cohen, 2004). A practical approach to achieve this is by integrating family and/or friends into physiotherapy planning. Tailoring physiotherapy sessions in collaboration with patients and their relatives may offer affirmation of their problem-solving capabilities in daily life challenges. Additionally, it facilitates discussions regarding patients’ experiences with their health condition or disability and provides opportunities for education concerning the disease, technical aids, and ergonomics. These strategies were shown to be valuable and instructive for both patients and relatives, helping them understand each other better and resulting in a stronger bond in most cases (Cohen, 2004).

Physiotherapists also have a role in the direct provision of support, such as referring for material support as needed (e.g., walking aids, orthosis, oxygen therapy) and linking the individual with other sources of information and emotional support (e.g., therapy team, relevant societies). They can also help decrease catastrophic appraisal of situations by outlining anticipated functional improvements so that the perception of severity is more manageable, and providing examples of how other individuals have coped (Sullivan and Adams, 2010). In addition, they can give individuals and their caregivers affirmation of their own abilities to resolve problems in everyday life, and when an individual’s needs and capacity do not correspond, show alternative ways of resolving problems in both thought and action (Nätterlund and Ahlström, 1999). Finally, supporting caregivers with information (e.g., how to do wheelchair transfers, how to adapt the working and home environments to meet the individual particular needs) so that they do not solely rely on emotional coping is vital, as this can help relieve some of the burden related to dealing with potentially unknown situations and positively affect the assistance they can provide over the long term (Reinhard, Given, Petlick, and Bemis, 2008).

Another way physiotherapists can strengthen an individual’s social support network is by developing the individual’s existing or new social skills. Through a holistic approach where exercises and activities are aimed at learning, acquiring, and training physical and mental skills required to function independently in society (e.g., focus attention, remember instructions, prioritize tasks, empathize, plan, and cope), physiotherapists can significantly contribute to improve one’s emotional wellbeing and ameliorate their social affective functioning (Koekkoek, van Meijel, Schene, and Hutschemaekers, 2010). In improving social abilities, the goal is to increase individuals' participation in everyday activities and contribute to building a wider and stronger social support network.

The importance and benefits of activity and social participation in people’s lives have been reported in relation to several chronic conditions, such as COPD (Halding, Wahl, and Heggdal, 2010), stroke and arthritis (McPherson, Brander, Taylor, and McNaughton, 2004), Parkinson’s disease (Hunter et al., 2019), and cancer (Vrkljan and Miller-Polgar, 2001). In this sense, considering group therapeutic settings in physiotherapy may contribute to a sense of belongingness, self-management skills, self-care behavior, and alleviate the negative psychological aspects of the disease through sharing experiences and increasing social connections (Halding, Wahl, and Heggdal, 2010). On the other hand, not all patients may like or be suited to group activity. For example, some individuals may feel excluded by the group if they are joining for the first time a group that already has established relationships, and poor previously established relationships could also negatively impact group dynamics. Borek and Abraham (2018) described the mechanisms of how group-based interventions can promote individual behavior changes, including fostering social identification, interdependence, and validation. Alternative ways that have been increasingly recognized to effectively promote patient engagement and peer support are tele-based interfaces, such as mobile apps and social media channels. Studies have shown that online peer support groups are recognized to improve social well-being, enhance self-management and self-efficacy, and provide a sense of belonging across many chronic diseases (Chung, 2014).

Table 1 summarizes all the above-discussed strategies for including social support in physiotherapy through five main recommendations. These are only focused on the therapist level, nevertheless many other aspects of social support were not included as they would be beyond the scope of this manuscript. Recommendations were also based on reviews in different contexts (Hogan, Linden, and Najarian, 2002; Hunter et al., 2019).

Table 1. General recommendations to foster social support in physiotherapy.

Recommendation	Description
Assess the nature and strength of social support	Understand and critically evaluate different concepts and models of social support, select measures that differentiate the dimensions of social support and give preference to instruments that have been validated for specific patient populations
Emphasize the naturally occurring social networks	Incorporate family and/or friends into rehabilitation planning, allow them to attend the sessions, identify individuals to act as proponents of behavior change on the basis of network structural properties
Provide direct support	Refer for material support as needed, link the individual with other sources of information and emotional support, support caregivers in their role
Develop individual’s social skills	Engage in exercises and activities that encompass learning, acquiring, and training social skills required to function independently in society
Cultivate new social support systems	Encourage participation in peer support groups, promote group sessions, consider virtual groups (mobile apps, social media), break existing ties with those who foster and facilitate unhealthy, risky behaviors

There are several advantages to measuring the strength of the therapeutic relationship from the patient’s perspective, for whom most available tools have been designed. This allows the therapist to identify how comfortable their patient might be in sharing their thoughts, experiences, struggles, and goals with them throughout care. Understanding the bond one has with one’s patients is the first step toward strengthening that relationship. Nevertheless, having in mind that the therapist also brings their experiences and perspectives into the dynamic and that the therapeutic relationship is a collaborative and interdependent process, ways to measure the relationship from the therapist’s perspective can be explored – for example, instruments such as WAI – Short Revised Therapist (WAI-SRT) (Hatcher, Lindqvist, and Falkenström, 2020).

Consider this clinical scenario; a young man recovering from a shoulder sports injury feels dissatisfied with his physiotherapy sessions. He does not feel heard and involved in his care, but he does not know how or does not feel comfortable approaching the physiotherapist to address it. The physiotherapist uses a questionnaire to gather feedback on their therapeutic relationship and realizes it was rated as suboptimal. Based on the specific feedback, the physiotherapist adjusts their communication style, starts practicing more therapeutic listening and demonstrates more empathy toward his emotional state. Finally, the physiotherapist allows the patient to choose therapeutic approaches that align with his preferences and comfort. This leads to improved patient engagement and treatment outcomes. This example shows how utilizing feedback questionnaires can serve as a valuable starting point for identifying and addressing underlying issues that may compromise the quality of care. However, a balanced approach that emphasizes open communication and reflection of the therapeutic process is essential to prevent an overestimation of the therapist’s abilities or the therapeutic environment’s safety.

O’Keeffe et al. (2016)and Babatunde, MacDermid, and MacIntyre (2017) identified factors that influence the therapeutic alliance in musculoskeletal physiotherapy and occupational therapy practice. Moreover, Miciak et al. (2019) developed a framework for establishing connections in physiotherapy practice that offers a conceptual understanding and practical knowledge on how to establish connections between physical therapists and patients, as well as how to support physiotherapists and other rehabilitation providers to reflect on their practice and operationalize an approach to developing the therapeutic relationship. Table 2 summarizes the findings from these studies, providing some general recommendations to promote, maintain, and repair a strong therapeutic relationship in physiotherapy.

Table 2. General recommendations to promote a strong therapeutic relationship in physiotherapy. This table summarizes the findings from (O’Keeffe et al., 2016), (Babatunde, MacDermid and MacIntyre, 2017) and (Miciak et al., 2019) articles and provides additional insights.

Recommendation	Description
Utilize feedback	Incorporate patient feedback into treatment planning and implementation
Adopt a good communication style	Practice empathic listening, explore nonverbal body language, and clarify the information provided
Foster connectedness and friendliness of the therapist	Show kindness, compassion, empathy, warmth, encouragement, and engage the patientin their treatment
Demonstrate professional skills	Experience, reputation, expertise, and level of training
Engage in reflective practice	Cultivate self-knowledge and self-awareness to align with the patient’s needs, goals, and values
Establish roles and responsibilities	Clarify roles of both the patient and therapist including accountability for those responsibilities
Deliver individualized patient-centered care	Provide treatment that is specific and responsive to patient needs
Encourage shared decision making	Involve patients in the decisions about their treatment and take their opinions into account
Ensure congruence in goals and clear expectations for the process	Establish similar expectations with patients regarding their goals for overall care and within sessions
Consider organizational and environmental factors	Allow time and flexibility with care and appointments
Acknowledge the uniqueness of each individual	Create egalitarian relationships (i.e., meeting as an equal), validate the patient’s subject life experiences, be curious about their upbringing, culture, environment, family, and other life experiences that have impacted how they experience safety and trust in relationships, avoid assumptions or stereotypes
Giving of oneself	Invest mental, emotional, and physical energy as needed, within and beyond direct patient-therapist interactions
Utilize the body as a focal point to establish connections	Clarify physical problems and solutions, facilitate the patient’s connection to the body, and use touch to bridge a potential affective gap, conveying acceptance and caring
Address any conflict or disruptions in the therapeutic relationship trajectory	Resolve conflicts by recognizing one is occurring and then addressing it by, for example, providing a rationale for a task patients may be struggling with or revisiting treatment goals to align expectations

Although authors have previously concluded that therapists’ awareness of these factors could improve patient interactions and treatment outcomes, they also highlighted the need for future research to explore the mechanisms to best enhance these factors (O’Keeffe et al., 2016). In addition, there is a need for studies focusing on strategies to increase therapists’ capacity to develop interpersonal and communication skills for enhancing therapeutic relationships in clinical practice (Babatunde, MacDermid, and MacIntyre, 2017).

Conclusion

Human relationships can create a health-promoting environment, bolstering inner motivation and self-efficacy for the patient’s desired lifestyle. In line with the biopsychosocial model, psychosocial mechanisms such as social influence, social engagement, person-to-person contact, and access to resources (such as the ability to work and engage in recreational activities) influence pathways to health outcomes. Social support and therapeutic relationships are complementary aspects of one’s health care, and it is crucial to account for both in physiotherapy practice. This paper outlines several ways to do this based on the available literature; however, future research is warranted to further explore the breadth of patients’ social support needs and the pathways by which health outcomes are impacted in specific clinical populations. Despite the growing interest and significant advances in understanding the therapeutic relationship in physiotherapy, there is still a need to develop a comprehensive theoretical model and tools to evaluate social support provided by physiotherapists in the context of disability and physical rehabilitation. In addition, more studies exploring strategies to enhance therapists’ interpersonal and communication skills for improving the therapeutic relationship in physiotherapy practice are needed.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/09593985.2024.2372687

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.