Therapeutic Alliances

two men shaking hands

How the patient-therapist connection builds business

By Stephen Rapposelli, PT

The concept of therapeutic alliance might be a foreign one to many physical therapists and private practice owners. I never heard of it in physical therapy school!

The therapeutic alliance (also referred to as the working alliance) is a description of the interaction between the physical therapist and their patients and is considered an important aspect of the therapeutic process and can have an impact on treatment outcomes. In 1979, psychologist Edward Bordin noted that the strength of the alliance makes a difference in therapy, writing that “the working alliance between the person who seeks change and the one who offers to be a change agent is one of the keys, if not the key, to the change process.”1 Bordin’s research suggested that the working alliance is universal, applying to any scenario in which a person seeks help from others to change.

This concept is important because the stronger the therapeutic alliance, the stronger the connection between patient and caregiver. The stronger the connection, the better the compliance. The better the compliance, the better the outcomes. The better the outcomes, the more repeat and referred business back to your staff and your business.


The buzzword in leading-edge health care and wellness is “engagement.” Client engagement is an essential yet challenging ingredient in effective therapy. Engaged clients are more likely to bond with therapists and counselors, endorse treatment goals, participate to a greater degree, remain in treatment longer, and report higher levels of satisfaction. Gone are the days where the caregiver dictates to the patient from above, perhaps handing a sheet of exercises to be performed at home. You (and/or your staff) must acknowledge that it is indeed “different” these days, and health care customers are increasingly demanding greater say in their care.

That, my friends, is a good thing for me and you! All those great soft skills that you took for granted are in great demand! (Your kids can’t believe how “cool” you really are!)

Soft Skills that Create Engaged Health Care Customers

Let’s describe them in terms of how you were great at dating back in the day (stay with me here):

  1. You looked your date in the eyes, and you took care to sprinkle their name in the conversation (thank you, Dale Carnegie, who reminded us in his book, How to Make Friends and Influence People, that the sweetest sound to a person’s ears is the sound of their own name!)2
  2. You made the conversation about THEM, not you (at least not mostly about you)
  3. You were positive and spoke of the future optimistically.
  4. You focused on them, not the person at the other table, and certainly not your phone.
  5. After the date, you already had a plan for the next date that was exciting and made the other person look forward to seeing you again.

You see how having a good date establishes a connection and increases the likelihood of future success? That is very similar to what you do as a master clinician in establishing a connection to your patient. Relationship-building is the same, whether it is personal or professional (i.e., therapeutic).

Making the patient the hero of their own story is a fantastic technique in developing a therapeutic alliance. As Donald Miller eloquently describes in his great business book, Building a Story Brand, effective connection comes from telling a story of the patient where they are the hero, and you are the guide, not a story where YOU are the hero. He uses the plot and characters of the movie Star Wars as an example of this concept.

In Star Wars, the hero is Luke Skywalker. Luke has a problem: Darth Vader wants to kill him (more or less). Luke comes in contact with a guide, Obi Wan Kenobi. The guide (Obi Wan) helps the hero (Luke) achieve his goal and they all live happily ever after (except Darth—he dies).

This is actually the plot of every great story.

You can use this framework easily to establish a great therapeutic alliance. Your patient (the hero), has a problem (their bad shoulder/knee/back). The guide (you/your staff/your business) shows the hero the path forward. When you can tell THAT story to your customer, you have established a therapeutic alliance!


A therapeutic alliance helps you get your customer (patient) to do what is needed in order for them to feel better and function better? How?

Carl Rogers, widely regarded as the founder of client-centered therapy, established three central components of the therapeutic alliance3:

  1. Empathy
  2. Congruence
  3. Unconditional positive regard


In our scenario, this means agreeing on the goals of treatment. As a novice clinician, I am embarrassed to admit I never clearly expressed what my goals were of treatment, let alone acknowledging and coming to agreement with the PATIENT’S goals! It must be said here that expressly stating the patient’s goals out loud and getting agreement is paramount in establishing empathy (e.g., “Hey, he understands me.”)


This is the concept of reaching agreement on the pathway to the goals or the tasks required to accomplish the goals. In other words, “In this alliance, I am going to be responsible for certain things, and YOU—the patient—are going to be responsible for certain things. If we both hold up our ends of the contract, everyone wins.” Notice that there is communication and agreement that there is an alliance of a shared task. It is no longer “I am going to do something to YOU,” rather it is US doing something TOGETHER.

Unconditional Positive Regard

As we move toward a value-based payment model, our ability to engage patients in a manner that inspires them to participate in their own care will make the difference between the therapists who succeed and those who do not. A fundamental element of a successful patient outcome will be the therapeutic alliance—and it’s something we should all get very good at.


On a most basic level, we as physical therapists have something as our “secret sauce.” That secret is trust. Our patients trust us.

That means that we will ALWAYS have a competitive advantage over everyone else on the planet that wants to sell something to our patients. We have their trust. As a business (and industry), we should be guarding that trust and using it appropriately to recommend (and better yet, provide) synergistic goods and services that will help our patients to maximize their health span and lifespan.

For example, when I scroll through my Facebook feed, I see that I can buy everything from an electromagnetic mat that emits something to make me feel young, to weighted axes that I can whip around my room in order to look like one of the Avengers. How do I know if I even need that as a consumer?! Do they know me? No, they do not. But, if I had my own physical therapist, someone who knows my body, my injury history, and all my odd quirks, they could tell me what I need. I would trust my physical therapist and would consider them as a personal “cabinet member” who advises me on health optimization, not just injury rehabilitation.

By establishing and maintaining a therapeutic alliance with your patients, you have a customer for life! 

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1Bordin ES. The generalizability of the psychoanalytic concept of the working alliance. Psychother. 1979;16(3):252–260. doi:10.1037/h0085885

2 Carmody DP, Lewis M. Brain activation when hearing one’s own and others’ names. Brain Res. 2006;1116(1):153-158. doi:10.1016/j.brainres.2006.07.121

3Rogers CR. Client-Centered Therapy. Boston: Houghton Mifflin; 1951.

Stephen Rapposelli

Stephen Rapposelli, PT, is a PPS member and owner of Performance Physical Therapy, as well as Stretchplex, located in Delaware. He can be reached at

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