We’ve all been taught it, whether in school, clinicals, or as new graduates: the therapeutic relationship is the foundation of patient care. This is especially true in the therapy and rehabilitation field, where patients and clients interact with their clinicians over a long period of time, sometimes multiple times per week. Given the frequency of interactions, as well as the duration of treatment plans, success depends on a strong working relationship between the therapist or clinician and the patient.
Understanding that is good and all, but what factors can influence the therapeutic relationship? And how does this patient-therapist relationship and interaction affect the patient’s experience of treatment?
We’ll cover one big part of that relationship in this article: communication.
Communication & The Therapeutic Relationship
As we’ve also discussed here and here, many factors influence a patient’s experience in our clinics. It should seem pretty obvious, but one of the greatest factors affecting patient experience during a treatment plan is the interaction that patient has with their therapist. This starts with the way the therapist and patient communicate, including language, word choice, body language, and active listening. These interactions involving communication sends signals to patients about what the clinician expects or where the priorities lie.
For example, how a clinician communicates to a patient not only relays information, but also provides opportunities to demonstrate respect, responsibility, expertise, decision making, and prioritizing. This plays a large role in the biopsychosocial model of healthcare and rehabilitation, where patient-centered care is the focus of assessment, treatment planing, and goal-setting.
What do you pay attention to?
As an example, the information that a clinician chooses to focus on or pay attention to sends cues to the patient about what that clinician truly cares about. A recent study published in 2015 showed that despite clinicians saying that patient-centered care is the most important, many clinicians tend to prioritize their biomechanical frame of reference over the patient’s experiences or perceptions . And this is understandable. Most clinicians go through school and start work in an environment where third-party payers and regulators prioritize “definable, measurable, quantifiable” treatments and goals. Outcome measures rule the roost of the rehabilitation world. If we’re not careful, clinicians can fall into a rut, reducing every patient to a diagnosis with associated metrics.
“At 09:00, I’ve got a rotator cuff that’s only got 75 degrees of abduction.” How many times have you heard this in the clinic? How many times have you yourself said something similar? You may not realize it, but patients pick up on these statements —and the values they communicate— and internalize them.
Truly Patient-Centered Communication
When a therapist asks “How do you feel?”, the patient may first share more personal perceptions or emotions. “I’m really bummed that I can’t run anymore.” “I feel like I can’t do much around the house.” When patient’s say these things, they are opening themselves up, becoming vulnerable to their clinicians. These responses reflect emotion, and they’re hoping that their clinician will acknowledge it . This is a great opportunity for the clinician to build the therapeutic relationship, empower the patient, and greatly improve their outlook and experience of treatment. Unfortunately, many therapists will breeze right over the emotions and go straight to the technical aspect. “What’s keeping you from running?” “Why don’t we work on xyz to get you back to doing things around the house?”
While these answers may be technically appropriate (we’re trying to fix a problem, right?), by skipping straight to the “nuts and bolts”, clinicians miss out on the opportunity to strengthen the therapeutic relationship. These patients want validation, or at least acknowledgement, of their feelings about their condition or dysfunction. They want their clinician to understand and care about what they themselves are going through. Therapists that make this effort tend to be regarded in higher esteem by their patients, and in the process are able to make real impact in their lives.
How to Use Communication to Improve Patient Experience
Understanding how communication influences the patient experience and the therapeutic relationship is one thing, but how can you actually make changes?
Research has shown that there are a few key areas that impact the therapeutic relationship and communication between clinician and patient. This list includes: interpersonal & communication skills, therapist’s practical skills, individualized patient-centered care, and organizational & environmental factors . Each of these areas could be the subject of their own article or book, but we’ll try to focus on those directly related with communication. This includes the interpersonal & communication skills of the therapist. This theme breaks down into a few different sub themes:
- Active Listening
- Nonverbal Communication
Let’s look at each individually.
Research shows that both clinicians and patients feel that active listening is important . It allows clinicians to hear their patients’ stories. When patients feel heard, they feel valued. When patients feel valued, they begin to form bonds with the clinician.
On the other hand, when patients feel ignored or interrupted, they become frustrated, upset, or even disengaged. When patients become disengage they inconsistently adhere to their home programs, miss appointments, or drop treatment altogether. By simply taking the time to actively listen to our patients, we can make a huge positive impact both in their participation and engagement in treatment as well as their overall experience of their time in the clinic.
Empathy on the part of the therapist also improves the overall patient experience by helping to develop positive patient-therapist interactions. In fact, research shows that many clinicians consider empathy a fundamental part of the therapeutic relationship . Empathy allows clinicians to take into consideration any pain, suffering, or discomfort that the patient may be experiencing during the treatment process.
Patients also feel that it is important for their clinicians to truly realize how much of an impact their pain or dysfunction has on their daily lives. Therapists have the opportunity to show empathy both during treatment as well as when practicing their active listening. It may not seem like much, but a clinician saying something as simple as “I’m sure it’s difficult to not be able to walk your dog” can have a huge impact on that patient’s outlook on treatment as a whole.
This one seems like a no-brainer, but it’s funny how many clinicians miss the mark when it comes to being friendly. Most clinicians aren’t outright mean or anything like that. They just tend to “get in the groove” or are preoccupied with the technical side of healthcare that they forget simple things like small talk or idle chatter with their patients. Missing this, however, can have lasting impacts on the patient’s overall view and experience of the treatment and care they receive in the clinic. Research shows us that many patients believe that being able to “chat” with their clinician in a friendly manner is very important for positive patient-therapist interactions . It also lays the foundation for a more open and honest relationship with the clinician. If a patient feels you really listen and care about what their grandson is doing in school, or their spouse is doing for work, they will begin to open up about more personal details —like how this condition is affecting their function.
We’ve all been there: slammed with back-to-back patients, and some complicated cases mixed in. Maybe the patient we are seeing is particularly complex. Whatever the case, it’s easy for clinicians to turn their personalities off. I mean, after all, we’re there to try to figure out what’s not working and fix it. Despite this, it is vitally important that we make a conscious effort to simply be friendly with our patients and clients. Having a sense of humor or providing a friendly greeting goes a long way to impact your patients’ outlook on treatment. You’ll find that they become more engaged, tend to have better outcomes, and report higher levels of satisfaction with the treatment they receive if you just take the time to make small talk.
It may not seem that important, but patients report that when a clinician provides motivation or encouragement, it helps them feel that the clinician cares about them and helps to develop a strong therapeutic relationship . Encouragement motivates patients to adhere to their home programs and try to improve. Encouragement also provide emotional support to patients, which can even further deepen the bond between clinician and patient. When clinicians provide encouragement, patients feel reassured in their ability to recover, in their progress during treatment, and in the clinician’s care for them as individuals. It may be hard to remember, but we as clinicians need to be providing encouragement to our patients.
Regardless of setting or situation, nonverbal communication often carries the same —if not more— weight as the words we choose to say. This is no different when treating patients in a healthcare setting. Especially in assessment and treatment, nonverbal communication can make or break the chances of developing trust and building a strong working relationship between patient and clinician. Patients report that when their clinician acts in what they feel is an appropriate manner, they feel more comfortable and trusting of them . This includes not only the clinicians posture, but also how the clinician manages physical contact with the patient.
Often in the healthcare field, clinicians must touch their patients. This may be for assessment or treatment purposes. How we manage these situations has much more of an impact on the therapeutic relationship and patient experience than we realize. When I teach graduate occupational therapy students in kinesiology or treatment labs, I always stress the importance of following what I call “permission-based” manual therapy.
The idea is that patients make themselves extremely vulnerable in out clinics, especially when they are laying down on a mat during manual therapy treatments. The way clinicians handle these situations can either greatly build or detract from the therapeutic relationship and, ultimately, that patient’s overall experience of treatment. By following a “practice-based” model, the clinician creates a secure environment where the patient feels safe, comfortable, and open to receiving treatment and giving feedback to the therapist. That helps build the therapeutic relationship, improves clinical outcomes, and results in a uniquely impactful patient experience.
Besides technical skills, ability, and knowledge, patients truly value a clinician’s communication skills. Clinicians that are friendly, empathetic, and active listers leave their patients feeling valued and cared for in a way that has real impact on both clinical outcomes and patient satisfaction with treatment .
Taking the time from the beginning of treatment to practice active listening, empathy, friendliness, and providing encouragement has a great impact on a patient’s outlook of treatment. Creating a space where the patient feels safe, secure, and comfortable helps strengthening the therapeutic relationship and improves the patient’s outlook on treatment. This means making a concerted effort to put these things into practice. Clinicians should consciously try to improve their active listening and —as hard as it may be— engaging in friendly small talk with their patients. This makes patients feel valued and cared for, and will make them feel secure enough to open up about deeper issues and challenges that may be impacting treatment or recover.
At the end of the day, we just have to remember that our patients are’n just a diagnosis. They are real, unique people, with unique circumstances that affect their treatment and recovery. Taking steps to understand this will help inform our treatment and practice, while at the same time delivering a uniquely impactful patient experience.
Have you tried to make any changes to the way your clinicians and staff when communicate with patients to improve their overall experience in your clinic? Share any additional resources that you found helpful in the comments below!
For more informational reads, check out our Blog to see all the articles we’ve published to date. Click here to head over to our resources section and check out our variety of clinical and professional resources aimed at increasing your knowledge and skills. If you’d like to make some changes in your clinic or health center, and would like some help, check out our consulting and advisement services or contact us to see how we can help you break out of the norm and provide a truly impactful patient experience.
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 Josephson, I., Woodward-Kron, R., Delany, C., & Hiller, A. (2015). Evaluative language in physiotherapy practice: How does it contribute to the therapeutic relationship? Social Science & Medicine, 143, 128-136. doi:10.1016/j.socscimed.2015.08.038
 O’Keefe, M., Cullinane, P., Hurley, J., Leahy, I., & Bunzli, S. (2016). What Influences Patient-Therapist Interactions in Musculoskeletal Physical Therapy? Qualitative Systematic Review and Meta-Synthesis. Physical Therapy, 12(04), 163-165. doi:10.1055/s-0035-1567123
 Hush, J. M., Cameron, K., & Mackey, M. (2011). Patient Satisfaction With Musculoskeletal Physical Therapy Care: A Systematic Review. Physical Therapy, 91(1), 25-36. doi:10.2522/ptj.20100061