Therapeutic Alliances

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Alex Bendersky and I started a podcast, and in our second episode, one of the topics of conversation was the therapeutic alliance between a provider and a patient. This term is commonly used when describing the relationship between psychotherapist and patient as a requirement for patient success.

But it’s also fully applicable to the relationships between PTs, OTs, and STs and their patients. It’s an easy leap—both physical and behavioral therapists need the engagement of the patient and a collaboration in developing and achieving appropriate and patient-centered goals.

I’m here to call it out for you. 💬 

There’s a commitment required by the patient in PT, OT, and ST care, and every time the patient shows up for an appointment, they are re-committing to seeing their treatment regimen through its (evidence-based) course.

Therapists, both behavioral and physical, commonly spend many hours addressing one condition or episode.

To be professionally successful as a therapist in a patient-facing role, you have to be an excellent communicator. You must be able to gauge a patient’s commitment, ongoing engagement, motivation, etc. This is actually a key superpower of the therapy professional. 🔑 🦸 

There’s no medication to prescribe, no invasive procedures to perform, no injections to give…a therapist’s most important modality is between their ears and with their voice, ears, perceptions, and attention.

Yes, I mean for physical and behavioral therapists.

The rehab therapist professional must be able to verbally engage purposely with each patient at each encounter while they are often doing manual work as part of the treatment plan, and have to process and modulate their treatment based on the multimodal feedback from the patient over the course of a 30-60 minute appointment. They have to be able to influence patients to do what is sometimes uncomfortable to painful, even when there’s little to know feedback or accountability between visits (although RTM and telehealth and asynchronous check-ins are starting to address this).

Okay, so what about physicians, nurse practitioners, and physician assistants and their role in therapeutic alliances?

Physicians in advanced primary care practices are or will have to rely more on developing and maintaining a therapeutic alliance between patient and provider than they have in the last several decades.

Why?

Because in value-based care, which is soon to be the predominant payment methodology and reimbursement mechanism in primary care, depends on successfully partnering on a longitudinal journey with a patient. These leads to fewer avoidable, unnecessary, emergency, and reactionary interactions with the healthcare system, where much of the high cost of care is found.

When successful at this, these provider groups are rewarded for reducing the TOTAL cost of care while payers are able to reimburse advanced primary care teams at higher rates in return so they can use it to leverage a new toolbox.

The Advanced Primary Care Triad

Right now, a common structure of an advanced primary care team is physicians, NPs and/or PAs, behavioral health providers, medical social workers, registered nurses, medical assistants, and community health workers.

All are practicing at the top of their license or certification.

In the ”able to bill payers” provider bucket, we have the medical providers and the behavioral health providers.

Commonly missing from these teams? Physical (and occupational) therapists.

And consider this, from the “Results” section of this article Abstract in JAMA on February 14, 2025:

So the conditions resulting in the second largest spending of all conditions are ones where the PT is most commonly the right provider for entry into the health care continuum. Remember, PTs are educated and licensed to screen for red flags indicating a physician and their scope of practice is needed.

Since so many of a primary care practices’ chronic and urgent care patient visits are related to MSK conditions, and since so much spend in the MSK space ends up circumventing PT in favor of medications, imaging, specialists physicians, emergency room visits, surgeries, post-acute recovery, and more, there should be a physical therapist on every primary care team.

Then they should be the first and often primary provider to assess and address pain, function, mobility, etc., and to help patients navigate the health system while patients remain anchored to the advanced primary care team as the quarterback.

There is simply MUCH less friction and more prompt intervention when the therapists is where patients are already presenting…

Their primary care providers’ office.

So advanced primary care teams or ones that are just seeds or plans, may I make a humble recommendation?

Make a change or start out right. Consider the medical, behavioral, and physical providers who belong on the team and put them in place right away. A cohesive therapeutic alliance between the whole team and each patient (and often their care partner) is ideal.

When primary care physician practices smartly choose this route, they add provider types to medical practices who are already experts in what they also must become experts in—developing and maintain strong therapeutic alliances with their patients.

You know what else?

They increase the likelihood of a wildly successful practice—professionally and financially!

How about this—up to one-third of patient visits to these practices could start with the Doctor of Physical Therapy instead of the Doctor of Medicine or Doctor of Osteopathy.

So for those patients with —

• arthritic pain or

• plantar fasciitis or

• balance training or

• caregiver training or

• rotator cuff tendinitis or

• chronic or acute low back or neck pain or

• who needs an assistive device and a home safety eval and modifications or

  so much more…….let the “non-physician doctor” see the patient first.

Know what else is great about full-risk advanced primary care?

Prospective payments and annual performance reconciliation mean there’s no “competing for RVUs” to “treat” a condition.

PT First is now more than a slogan or a professional wish. It’s aligned where it needs to be.

Want more on the future of healthcare? Subscribe to this newsletter, where you’ll get exclusive access to our growing Resource Database at our community, the Future Proof PT.

Here’s Episode Two of our unscripted podcast, the Future Proof PT Podcast, which you can also find on all podcast platforms 👇️ 

Here’s the audio if you want to listen audio-only right from here. It’s a little longer than some like to devote to a podcast but hey, there’s always listening at double-speed! 🤣 ⏩️ 👇️ 

That’s all for today!

Wishing you a quick week, and catch you back here next week. As always, thanks for being a member of the Timeless Autonomy community!

All the best,

Dana

This edition of the newsletter is also sponsored by Saatva!

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Until we got the Saatva Latex Hybrid in October, he woke up stiff on a good day and in pain on a bad day. Literally since our first night sleeping in the new bed, he wakes up comfortable every morning.

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So when they approached me about collaborating, I said absolutely.

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Please reply back if you have any questions! I’m happy to connect with you.