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Good Practice: Preparing For Challenging Therapeutic Relationships

An ounce of prevention is worth a pound of cure.

As physiotherapists, we are aware of the importance of developing positive therapeutic relationships with patients as well as the role these relationships play in achieving positive patient outcomes. Academics have discussed the hallmarks of effective therapeutic relationships and how to go about their development. While our patients may not be as familiar with the science of the therapeutic alliance, it’s fair to say the majority enter the therapeutic relationship openly, honestly and with good intention.

Every now and then, however, you will encounter patients or situations that require extra diligence and effort to build a positive therapeutic relationship. Having worked for the College of Physiotherapists of Alberta for a few years now, I can say that no therapist is immune to these circumstances. During my time here I have heard from both new clinicians and seasoned veterans experiencing this for the first time.

Though obvious, it bears stating that there are two parties in any therapeutic relationship, and people are complicated. Part of working in health care is recognizing that some people have a harder time developing a trusting relationship with healthcare professionals than others, Regardless, its our responsibility to do our best to create rapport and treat them.

Every patient you encounter is juggling multiple priorities and challenges, including the illness or injury that has brought them to you. It’s also important to recognize that other factors can play a significant role in the patient’s life and the attitude they bring with them to physiotherapy. The same can be said for all of us. In tough times when people feel financial pressures or general uncertainty, these concerns can factor into the patient care encounter and the ability to build an effective therapeutic relationship.

In times of pressure or uncertainty, it seems the threshold for what people can tolerate in the form of poor service, ineffective communication, or less than optimal outcomes is lower than before. The College of Physiotherapists of Alberta does see these situations when times are good, but in tough times there seems to be less tolerance on both sides of the therapeutic relationship.

How can you recognize the difference between the patient you don’t quite hit it off with and the therapeutic relationship that is about to go sideways? How do you prevent things from ending poorly? First and foremost, pay attention to what the patient is telling you. Although there may be good explanations for past experiences and attitudes, there are some indicators that you may want to pay attention to.

  • The patient’s history is one of persecution or victimization. To be clear, there are people in the world who have been victims of terrible injustice. However, when a person’s story is one of victimization, whether real or perceived, it warrants that we proceed with empathy and caution.
  • The patient has a history of multiple past providers, both physiotherapists and other professionals, that they have “fired,” or who ended the therapeutic relationship leaving the patient without a care provider.
  • The patient is not satisfied with those past providers but is (initially) ecstatic with you and the care that you provide.
  • The patient’s initial treatment response is wildly inconsistent with the treatment provided, your past experience, and your expectations for the patient’s response to treatment.

Given that you may not see these situations coming, here are some universal precautions to apply daily to help mitigate the risks with more complex patients:

  • Limit personal disclosures. While it is important to be warm and collegial and to build a therapeutic relationship with your patients, you also need to be cognizant of the limits of what you are comfortable to disclose. Ask yourself what you want your patients to know about you, and carefully consider how what you share could be repeated or reinterpreted in the future.
  • Monitor your patient interactions, your tone, and choice of words. This goes hand in hand with limiting personal disclosures. Remember that the Code of Ethical Conduct requires us to conduct ourselves in a manner that maintains the public’s confidence in the integrity and dignity of the profession. Though it can be difficult at times to hit the right balance between being friendly and appearing professional, being overly familiar in your interactions with patients can erode the perception of professionalism required of us by colleagues and expected by our patients.
  • Charting! Admittedly, it’s a cliché when regulators talk about charting, but we do so for good reason. Quality charting is the best prevention any time a conflict, concern, or complaint arises. Completing thorough charting of every treatment session or other patient contact (e.g., phone calls) as they happen helps to assure the accuracy of what is documented. In the words of the College of Physiotherapists of Alberta’s Complaint Director: “If it’s charted after the fact, it’s fiction.”
  • Monitor your assumptions about patient consent. Make sure you have consent and don’t assume that because the patient showed up, they agree with the plan. Document how you provided information to support informed consent and how you determined that the patient understood that information, as well as the consent itself.
  • Be consistent. There’s that old expression: “you teach people how to treat you.” If a particular behaviour bothers you, you need to speak up right away and let the patient know that it is not appropriate. If you don’t, you are part of the issue.
  • Set Boundaries. It is both reasonable and appropriate for physiotherapists to set boundaries around their interactions with their patients to ensure their ability to serve their entire caseload. Such boundaries may include limiting appointment lengths or setting boundaries about when, how, and the frequency of communication between patient and provider outside of appointment times.
  • Trust your instincts. If your Spidey senses are tingling, even if you can’t quite put your finger on why, trust your instinct and proceed with caution.

Monitor yourself

As was already stated, there seems to be less tolerance on both sides of the therapeutic relationship these days. it’s only fair to consider that the physiotherapist and their concerns can also be at the root of difficult therapeutic relationships. Monitoring your psychological well-being and getting help when needed is also imperative and is a requirement established in the Code of Ethical Conduct, which requires physiotherapists to “attend to their own health and well being” and to “take responsibility for their own physical and mental health and refrain from practicing physiotherapy when their ability to provide appropriate and competent care is compromised.”

Know when to say goodbye

Physiotherapists have the ability to discontinue treating patients when certain circumstances arise, including situations where the patient is verbally, physically or emotionally abusive, and situations where the patient does not adhere to the treatment plan. In such situations, physiotherapists need to ensure they facilitate ongoing care by providing the patient with information about how to access alternate service providers and transferring care as appropriate.

And if you do need to say goodbye, plan the conversation, be clear and consistent with your decision. Above all, keep in mind that although it’s almost a given that you will encounter a therapeutic relationship that goes sideways at some point in your career, the vast majority of patients and patient encounters will go smoothly and end well. For more information about managing challenging therapeutic relationships check out our Managing Challenging Situations Resource Guide.

Page updated: 25/04/2022