therapeutic alliance: a moral imperative and just …
TRANSCRIPT
8/30/18
1
THERAPEUTIC ALLIANCE: A MORAL IMPERATIVE AND JUST GOOD PRACTICE
An Ethics and Jurisprudence Course
Jill S. Boissonnault, PT, PhD, WCS
Course Objectives
Upon Completion of the course the learner will be able to:¨ Define Therapeutic Alliance (TA) and understand its
implications for rehabilitation medicine¨ Identify medical ethics principles and APTA Codes of
Ethics that apply the concepts of TA¨ Consider how TA impacts health outcomes, patient
satisfaction, & adherence to rehab and wellness advice¨ Identify risk management strategies concerning TA¨ Implement strategies to develop a good TA with clients
Outline
¨ Defining concepts¨ Ethics principles tied to TA¨ Lit review on TA
¤ TA in psychology and medicine¤ TA and EBP PT, including:
n Outcomes:n Adherencen Pt. Satisfactionn Improved Health
¨ TA measurement tools with application in PT¨ Malpractice and Risk Management¨ Strategies to better TA in PT
8/30/18
2
-Therapeutic Alliance-Working Alliance-Helping Alliance-Alliance-Therapist-Patient Interaction/Bonding
What is Therapeutic Alliance, anyway?
Definition of TA
¨ A working rapport, or connection between the patient and the therapist.
¨ Simply, the relationship between pt. and therapist¨ Sometimes termed, “Working Alliance” or the other
terms on the previous slide¨ Comes out of psychotherapy. Most tie it back to
Bordin’s 3 main components (Bordin, 1979) :¤ Therapist-pt agreement on goals¤ Therapist-pt agreement on interventions¤ The affective bond between pt and therapist; implies trust,
respect, and acceptance
Cleveland clinic video on empathy“If we could see inside other people’s hearts”https://www.youtube.com/watch?v=IQtOgE2s2xI
It is all about making a connection
8/30/18
3
Dimensions of TA:Therapist attributes contributing to TA
¨ Is pt.-centered¨ Is dependable¨ Collaborative¨ Competent and Credible¨ Trustworthy¨ Instills Rapport; warmth &
friendliness. A Caring Response¤ Provides emotional support¤ Is benevolent¤ Is responsive¤ Empathetic response
¨ Communicates successfully¤ listening skills, including
mindfulness¤ Using first-person language¤ Mindful of patients’ health-
literacy needs“Universal Tool Kit”-http://www.nchealthliteracy.org/toolkit/
¨ “Is present, receptive, genuine and committed”-(Miciak 2018)
(Howard 1976, Luborsky 1985, Greenson1965,67, Hall 2002, Horvath 1989, Takayama 2004, Pinto 2012)
Dimensions of TA:Patient and Pt-therapist contributions to TA
¨Pt. involvement and participation in POC and Goals (Babatunde 2017)
¨Pt. belief in the worth of the therapy(Gomes-Schwartz 1978)
¨Pt. motivation (Cheing 2010, Babatunde 2017)
¨Proxy efficacy beliefs; belief in therapist’s ability to treat effectively (Cheing 2010)
Rapport vs. Skill
¨ Patient-satisfaction studies find rapport more important than skill! (Roush, 1995, Davis, 1989; Schlenoff, 1994)
¨ Patients litigate less often when rapport is good! (Huntington and Kuhn, 2003)
¨ Rapport between pt. and PT influence self-efficacy (Moffett and Richardson 1997), → better therapeutic-outcomes
8/30/18
4
Ethics Principles and TA
The Virtue of Caring
¨ Caring or a Caring Response, is at the center of PT¨ Caring implies respect for autonomy¨ Caring implies we are competent¨ Ruth Purtillo notes, “A caring response includes
professional duty. It shifts the claim on you from a patient’s hope that you will offer a kind or even generous response to making it your duty to respond to the patient’s need.” (Purtillo 2005, p. 33)
¨ Caring ethic: is relational and fosters trust (Purtillo, 2005)
Caring & Patient-Client Relationships
¨ Caring is at the center of therapist-pt. relationships¨ Relationships between pts and PTs are moral, guided by
moral values and characterized by:¤ Concern and compassion for the pt¤ Sensitivity to pts’ needs¤ Empathy for pt suffering¤ Respect for pt rights¤ Conscientiousness on part of the PT¤ Understanding of pts’ issues through a biopsychosocial lens
(Gabard and Martin, 2011)
8/30/18
5
“All That Matters Is The Person…”Donald Berwick, MD (Berwick, 2010)
“But, now I will tell you a secret – a mystery. Those who suffer need you to be something more than a doctor; they need you to be a healer. And, to become a healer, you must do something even more difficult than putting your white coat on. You must take your white coat off. You must recover, embrace, and treasure the memory of your shared, frail humanity – of the dignity in each and every soul. When you take off that white coat in the sacred presence of those for whom you will care – in the sacred presence of people just like you – when you take off that white coat, and, tower not over them, but join those you serve, you become a healer in a world of fear and fragmentation…”
-Watch the selection of a TED talk by Helen Riess-Reflect with your neighbors: How does her thoughts on empathy apply to the case on the next slide?
https://www.youtube.com/watch?v=baHrcC8B4WM&list=PLFPDmaMM5XCuQEyZfgh-VMxzxaqsOe4z3
Activity 1
Case to Reflect Upon with Dr. Reiss’ Thoughts on Empathy
¨ 63 year old woman¨ CC: bilateral Knee OA¨ Seen in an OP PT clinic¨ PT frustration:
¤ Pt. would ramble about her pain and frustration
¤ Hard to get her to focus on her response to Rx
¤ When specific questions were posed, she would not answer them and cont. speaking about her general Sx or other medical problems
¨ Solution¤ Accidently, 1 visit, PT
allowed the “rambling” for 5 min. and in a break, inserted a specific questionn Pt. answered!n Continued to be focused on
what he was asking¤ PT continued with this
strategy; pt. cont. to respond well.
¤ PT would respond, thereafter with a reframing of her “rambling”n “Good for me to know”n “Helpful for me to know”n “that is helpful information”
8/30/18
6
Medical Ethics Principles & Moral Values
¨Beneficence ¨Non-Maleficence¨Respect for Persons¨Justice
Relates directly to the virtue of caring
APTA COE Principles applying to TA
¨ PT COE: Principles 1, 2A, 2B, 2D¤ And somewhat, 2C, 3A, 6A, 8D
¨ PTA COE: Principles 1, 2A, and 2B¤ And somewhat, 2C, 3A and 6A
APTA Core Values and TA
¨ Altruism¨ Compassion and Caring¨ Excellence¨ Professional Duty
8/30/18
7
TA in psychology and medicine
Horvath, 2001, in PsychotherapyThe Alliance (a meta-analysis)
¨ Reviewed 90 independent clinical investigations¨ Determined TA to account for up to half of all
benefits of psychotherapy
Therapeutic or Working Alliance has been said to be the cornerstone of a successful psychotherapeutic outcome
Fuertes et al, 2006The Physician-Patient Working Alliance
¨ 118 pts. With chronic medical illnesses¨ Studied responses on WAI and pts.’ ratings of self-
efficacy, Rx adherence, pt. satisfaction and perceived utility of Rx
¨ Strong correlations between WA and all 4 pt. self-ratings
¨ WA and self-efficacy predicted pt. adherence¨ WA predicted pt. satisfaction
8/30/18
8
Fuertes, cont.
¨ Conclusions¤ The researchers note the importance of self-efficacy to
adherence: n Pts. need to believe they can do the Rx regimen
¤ MDs need to collaborate with pts.; treat pts. In a way to ↑trust&liking;acknowledgethevalueofpt.input&agreement
¤ Pts.andMDneedtoagreeonthecourseofRx(backtoBordin’s originalconceptofTA!-JB)
Impact of TA in Rehabilitation on:-Pt. satisfaction-Pt. adherence-Health outcomes
Therapeutic Alliance and EBP PT
Hall et al 2010, PTJ: The Influence of Therapist-Patient Relationship on treatment Outcome in Physical Rehabilitation: A Systematic Review
¨ 13 studies¨ Results showed TA associated with:
¤↑adherenceinpts.withbraininjuryandinpts.withmultiplepathologies
¤↓depressiveSx inpts withbraininjuryandcardiacconditions
¤↑Rxsatisfactioninpts.withmusculoskeletalconditions¤↑physicalfunctioningeri pts.andinpts.withchronicLBP
¨ TheWorkingAllianceInventory(WAI)usedmostoften
8/30/18
9
Hall, cont.
¨ Limited data, but suggested these factors most positively correlated with outcomes in physical rehabilitation:¤ Providing positive feedback¤ Answering pts.’ questions¤ Providing clear instructions for HEP
TA in Rehab &Patient Satisfaction
Ambady, Koo, Rosenthal and Winograd, 2002: PT’s Nonverbal Communication Predicts Geri pts Health Outcomes,Study 1 (Reviewed in the Hall Sys. Review)
¨ Judges reviewed video snippets of PTs with geri pts.¨ Rated on 17 interpersonal characteristics & non-
verbal behaviors¨ Outcomes were impacted by PT’s positive affect
including:nfacial expressions
n[smiling, nodding, furrowed brows]=empathy →↑satisfaction
8/30/18
10
Beattie 2002: Pt. Satisfaction with Outpatient Physical Therapy: Instrument Validation
¨ Pt. Satisfaction related to:¤ Pt.-practitioner relationship
n Competencen Personality of the practitioner
n Communication
¤ Location and accessibility of services¤ Continuity of care¤ Cost and payment issues¤ Aspects of the facility
Beattie 2002, cont.
“Our Findings indicate that adequate time spent in pt. care and the professionalism of the therapist and clinic staff are more important for patient satisfaction than are the location of the facility, the quality of the equipment, and the availability of parking.” P.563
Patient Satisfaction with Musculoskeletal Physical Therapy Care: a Systematic Review. (Hush et al, 2011)
¨ Pt.-centered care is a paradigm; Pt. satisfaction is a quality indicator
¨ 15 studies reviewed; in only 3 was Rx outcome or Sximprovement identified as important to pts.
¨ Therapists’ attributes were main determinants of pt. satisfaction¤ Skill and knowledge¤ Friendly attitude¤ Effective communication (ability to explain pt. role, condition, and
prognosis)¤ Professionalism¤ Demonstrating empathy¤ Consultative approach
8/30/18
11
TA in Rehab &Health Outcomes
Ferreira et al, 2013 PTJ (assessed in Hall’s Sys review)The Therapeutic Alliance between Clinicians and Patients Predicts Outcome in Chronic LBP
¨ Used the WATOCI (Working Alliance Theory of Change Inventory): 182 pts. completed it >RX
¨ TA predicted all final outcomes measured at 8 wks:¤ Global perceived effect of treatment¤ Function¤ Pain¤ Disability
¨ The>theTA,the>theseoutcomes
8/30/18
12
Fuentes et al, 2014, PTJEnhanced TA Modulates Pain Intensity and Muscle Pain Sensitivity in Patients with chronic Low Back Pain
Ambady, Koo, Rosenthal and Winograd, 2002: PT’s Nonverbal Communication Predicts Geri pts Health Outcomes, Study 1
¨ Judges reviewed video snippets of PTs with geri pts.¨ Rated on 17 interpersonal characteristics & non-verbal
behaviors¤ Positive affect
n facial expressions n [smiling, nodding, furrowed brows]=empathy →↑improvementinADLS&↓confusion
n lackofsmilingandlookingaway;physicalspace=distancing→negativeperception→↓ADLSandSTconfusion&depression
Their conclusion: Rx does not fully account for outcomes!
PEECE: a mnemonic (Barrett, 2006)
Positive prognosis: hope without deceptionEmpathyEmpowermentConnection (rapport)Education: giving pts. Control
¨ Barrett reviewed the literature and found these actions →↑healthoutcomes
8/30/18
13
TA in Rehab & Adherence
Schonberger et al, 2006: Working Alliance & Pt. Compliance in Brain Injury Rehabilitation & Relation to Psychosocial Outcome (Reviewed in the Hall Sys. Review)
¨ 98 pts. With TBI, Stroke or other neuro insult¨ Studied WA and Compliance
¤↑WA=↑Complianceandviceversa¤↑WA=↑ratesofpost-rehabemployment
Babatunde 2017: Characteristics of therapeutic alliance in MSK PT and OT practice: a scoping review of the literature
¨ 57% of articles assessing impact of TA on adherence showed some correlation between the 2
¨ TA characteristics predictive of ex. adherence:¤ Agreement on goals¤ Clear communication¤ Sense of connectedness¤ + feedback¤ Genuine interest¤ Individualized care¤ Trust in the PT¤ Helping pt. feel empowered
8/30/18
14
-Most are from psychology-One is for Pt. satisfaction with PT (MedRisk)
TA Measurement Tools
TA Measurement Tools
¨ WAI (Working Alliance Inventory) (Horvath 1989)
¤ Developed by psychologists based on Bordin’s 3 items of TA
¤ Short form is most widely used in research (Hatcher 2006)-See handoutn Adapted in one study for
medicine (Fuertes 2006)
¨ Vanderbilt Psychotherapy Process Scales: VPPS (Krupnick 1996)
¨ PRES (Pain Rehabilitation Expectations Scale) (Chieng2010)
¤ 3 subscales: Working alliance, Proxy efficacy, and Motivation/expectation
¨ MedRisk Instrument for measuring pt. satisfaction with PT care (Beattie 2005)-See next slide
The MedRisk InstrumentFor Measuring PatientSatisfaction with PhysicalTherapy Care(Beattie, et al,2005)
8/30/18
15
MedRisk Tool, cont.
¨ Pt. satisfaction can be a measure of TA¨ Analysis of the tool:
¤ “Being treated with respect by health care providers and being involved in treatment decisions are strongly linked to pt. satisfaction” (Beattie 2005, p.30), & include these constructs:n ‘My therapist answers my questions’n ‘My therapist gives me detailed instructions on my HEP’n ‘My therapist respects me’n ‘My therapist advises me’n ‘My therapists explains treatment’
Hatcher and Gillaspy, 2006
WAI-Short Form
WATOCI and Rehabilitation
¨ Working alliance Theory of Change Inventory (WATOCI) is the WAI-SF, with 4 items added to assess patient’s theory of change
¨ Hall, et al (2012) revised the WATOCI for rehab:
Think about goals, interventions and bond!
8/30/18
16
Pain Rehabilitation Expectations Scale (PRES)-(Chieng et al, 2010)
¨ 3 subscales: Working alliance, Proxy efficacy, and Motivation/expectation
¨ Proxy efficacy strongly related to WA¨ Proxy efficacy: belief in therapist’s ability to treat effectively
¨ WA positively related to client motivation and expectations¨ Chieng et al, are validating this scale with pain pts in PT;
¨ Suggest PTs enhance pt expectations to be + →↑outcomes¨ &WAenhancedwhenthePTispt-centered;theytailorRxto
individualandtothedisease
Notyetreadyforprimetime!
-Malpractice and TA-TA risk management strategies
to minimize litigation
Malpractice & Risk Management
Patients Won’t Sue Their Dr.s-Even When They Could (Mark Crane 2013)
¨ Studies show that physicians who spend more time answering questions and are candid with their pts. are sued less often
¨ Respect goes a long way; impacts pt. and family decisions on litigation
¨ Communication and good rapport discourages lawsuits; “Personality may be more important than clinical ability when it comes to lawsuits”
Accessed @: www.medscape.com/viewarticle/814876_print
8/30/18
17
Levinson, 1997 in JAMA on Pt.-MD Communication
¨ Oft sited study¨ Primary Care MDs’ communication style influenced
lawsuits. ‘No Claims’ MDs’ behaviors:¤ > use of orientation statements on what to expect¤ > use of laughter¤ > tendency to ask pt. opinions; check understanding
and encourage pts. to talkI.e., established > rapport(interestingly, no diff. between surgeons with claims and those without)
Risk Management
“Communication may be the best risk management tool available to you in stopping lawsuits before they happen, however, so pay careful attention to building rapport with your patients.” Lee J. Johnson, 2011
¨ Johnson discusses a study when pts. viewed scenarios of poor medical management and MD communication skills¤ Severe outcome →↑litigationtowardhospital,notMD(regardlessofTA)
¤ And,+communication→↓litigationforMDandhospital
Risk Management¨ The American Association of Orthopaedic Surgeons (AAOS)
has stated, “Good communication has a favorable impact on pt. behavior,
pt. care outcomes, and pt. satisfaction; as a consequence, it often reduces the incidence of malpractice lawsuits.” (Huntington 2003)
¨ AAOS considered pt.-focused communication to include:¤ Show empathy and respect¤ Listen attentively¤ Elicit pts.’ concerns and calm fears¤ Answer questions honestly¤ Inform and educate pts. about Rx options¤ Involve pts. In medical care decisions¤ Demonstrate sensitivity to pts.’ cultural and ethnic diversity (AAOS 2000)
8/30/18
18
HPSO Self-assessment Checklist for PTs
¨ See Handout(CNA HealthPro and HPSO, 2001-2010)
-Communication Skills-Establishing Rapport
-Increasing an Empathetic Response
Strategies to Better TA in PT
Dimensions of TA:Therapist attributes contributing to TA
¨ Is pt.-centered¨ Is dependable¨ Collaborative¨ Competent and Credible¨ Trustworthy¨ Instills Rapport; warmth &
friendliness. A Caring Response¤ Provides emotional support¤ Is benevolent¤ Is responsive¤ Empathetic response
¨ Communicates successfully¤ listening skills, including
mindfulness¤ Using first-person language¤ Mindful of patients’ health-
literacy needs“Universal Tool Kit”-http://www.nchealthliteracy.org/toolkit/
¨ “Is present, receptive, genuine and committed”-(Miciak 2018)
(Howard 1976, Luborsky 1985, Greenson1965,67, Hall 2002, Horvath 1989, Takayama 2004, Pinto 2012)
8/30/18
19
-Evidence about communicationand therapeutic alliance
-Verbal and Non-verbal communication
-Strategies for enhanced communication/TA & barriers to good communication
Communication
TA is mostly determined by:
¨How the patient and therapist communicate!¤Listening skills¤Asking about emotional issues (Pinto 2012)
¤Verbal and Non-verbal communication¤Being mindful; present in the moment
nDr. David Rakel, MD, “Pause, Presence, & Proceed(Rakel, 2013)
Patient-centered communication is associated with positive therapeutic alliance: a systematic review(Pinto et al, 2012)
¨ Therapeutic alliance (TA) was associated with positive Interaction styles that were:¤ Patient facilitating¤ Patient involving¤ Patient supporting
¨ Behaviors found to support TA: ¤ listening to what patients have to say¤ Asking questions ¤ Showing sensitivity/support to emotional concerns¤ Being patient-centered (see next slide)
8/30/18
20
Pinto, cont.
¨ Patient-Centered Behavior is behavior that involves:¤ A biopsychosocial perspective & understanding of the pt’s.
illness experience¤ Sharing power and responsibility¤ Developing a relationship based on caring, sensitivity and
empathy¤ Self-awareness and attention to emotional cues¤ Non-verbal pt.-involving behavior (leaning in, eye
contact(?), uncrossed legs)
The Importance of Body Language, Facial Expression, & Tone of Voice
¨ They say only 7% of communication is really verbal!
¨ 38% is by tone!
¨ 55% by body language!
(Mehrabian 1967)
Verbal vs. Non-verbal
¨ Verbal communication is influenced by cues characterized as, “paralanguage cues”¤ Tone of voice¤ Pitch¤ Volume¤ Speed
(Drench, 2012)
¨ Non-verbals (sent intentionally or unintentionally)¤ Facial expression,¤ Touch¤ Proxemics¤ Behavior
¨ May be the first impression!
8/30/18
21
Perry 1975 in PTJ: Nonverbal Communication During Physical Therapy
Perry, continued
¨ Importance of proxemics¤ Found that 80% of all observed treatments took place
in an intimate distance (within 46 cm, or an arm’s length)
¤ Unusual in day-to-day conversation in many cultures¤ This commonplace occurrence in PT probably enhances
rapport, caring, approval and acceptance
¨ 50% of the time, PTs were unaware of their non-verbals; opportunities exist to harness this tool
Ackerman & Hilsenroth, 2003: A Review of Therapist Characteristics & Techniques Positively Impacting the TA
¨ Reviewed much of the psychology literature on TA¨ Generated this list of characteristics + impacting TA:
¤ Communicating hope¤ Noting Progress¤ Understanding, accepting, respecting pts.¤ Being open minded¤ Being enthusiastic¤ Sharing common therapist-pt. experiences¤ Exhibiting feelings of working together¤ Communicating trust in pt’s. self-efficacy
8/30/18
22
Ackerman, cont.
Thornquist E., 1991Body Communication is a Continuous Process
¨ Observed 30 physios¨ Manual PTs were great at:
¤ Active listening (toBoth verbal and nonverbal comm.) ¤ Eye contact ¤ Posture indicated interest, approachability¤ Limited writing attentiveness, & caring¤ Adapted tempo/
rhythm
Practitioner-induced barriers to communication
¨ A dismissive, patronizing communication style (mostly written about in medicine) (Greene, 1986)
¨ Simplistic, baby-talk; infantilization to the elderly (Adelman1992, Caporael 1983)
¨ MDs found to initiate most of the conversation, especially with older clients (Adelman 1992)
¨ Other Barriers:¤ See Handout, “Communication Seminar Excerpts”, W. Boissonnault
8/30/18
23
Jensen, et al: Expert Clinicians are Pt.-Centered
¨ They are empathetic¨ They listen well¨ They can detect pt. confusion & know when they are
being understood¨ They seek clarification(Jensen et al, 1990)
Patient barriers to communication in TA
¨ Physical signs of aging (hearing visual and cognitive impairments)
¨ Differences in markers of diversity¨ Intergenerational differences, e.g.,
¤ Older generation may be unwilling to get personal¤ Younger generation may not share the same
perspectives¤ Older generation may not communicate with technology
(see next slide)¨ Again, See Bill’s communication excerpts handout
8/30/18
24
-Read the following case scenario-Watch the video-Discuss-Watch part 2 of the video
ANOTHER ACTIVITY!
Your new outpatient, “Todd,” is a 33 year old male welder from Portland, ME who was injured in a single car collision on Thanksgiving Day 2009. He was an unrestrained passenger in a car driven by his twin brother, who died in the accident. Both had been drinking.Todd’s injuries included facial lacerations, a fractured left radius, fractured ribs, and a T12 burst fracture. He reportedly was conscious at the scene (Glasgow Coma Scale=5). He was taken to Maine Medical center, where he presented with loss of movement and sensation in the lower extremities, loss of volitional bowel and bladder control, and considerable pain.Todd underwent immediate surgical fixation of his vertebral fracture and was placed post-operatively in a thoracolumbar sacral orthosis (TLSO). His left radial fracture was reduced and fixed in an external cast covering the forearm, wrist, and hand. He was placed on non-weight bearing precautions for the left arm. He was soon after transferred to New England Rehabilitation Hospital (NERH) for multidisciplinary therapy services.Because of his limited ability to use his left arm, Todd’s admission to NERH focused primarily on helping him develop a tolerance for sitting upright in a wheelchair and educating him and his family on his basic care. The forearm cast was removed in early January; the TLSO remained in place. With limited insurance coverage for inpatient care, he was discharged thereafter to live with his parents and younger brother in their Portland home.Today Todd arrives in a wheelchair for his first outpatient PT visit at NERH. He no longer is wearing a TLSO.
http://youtu.be/INxwqvv1n9Q
Communication-training video from UNE, courtesy of Jim Cavanaugh, PT, PhD
¨ Watch Part 1¨ In a pair, trio or 4-some, discuss what went poorly in
the communication between Todd and his therapist and social worker
¨ Then discuss what you would have done differently¨ Be prepared to share with the whole group¨ We will then watch Part 2(Cavanaugh & Conrad, 2011)
8/30/18
25
Establishing RAPPORT
See handout from Boissonnault, W.Communication Seminar Excerpts‘Strategies to develop Rapport QUICKLY!!’
The Challenge of Establishing Rapport in an Era of Social Media
N1 MIRL or F2F, AFAIK!
Social Skills: Impact of technology use on PTs?
¨ A study at the CT College found:¤ Participants who used technological communication
more frequently or preferred it to face-to-face communication, had lower social skills and high social anxiety
(Brown, C. 2013)
8/30/18
26
So….
¨ if we don’t develop skill at reading non-verbals, we won’t understand patient communication!
¨ We don’t know how to look people in the eye to make a connection!
¨ We have difficulty establishing rapport!
e-patients.net
Listening and Empathy; two important, but oft poorly executed skills!
Fuentes et al, 2014, PTJ(Enhanced TA Modulates Pain Intensity and Muscle Pain Sensitivity in Patients with chronic
Low Back Pain)-Revisited
¨ “TA relies on a complex interplay of technical skill, communicative competence, and the reflective capacity of the therapist to respond to the patient in the moment of therapy” (Crepeau p. 873, 2011, as quoted in Fuentes)
¨ We will now examine a video providing training to the “enhanced TA groups”
http://ptjournal.apta.org/content/94/4/477./suppl/DC2¨ What did you think?
8/30/18
27
Rapport and an Empathetic Response
TA requires a bond between therapist and client/patient. Empathy=Connection
¨ Empathy: Coulehan et al (2001),
argue that empathy has 3 components:¤ A cognitive focus: one enters into
the perspective and experience of another, but does not loose one’s own perspective or professional distance
¤ An affective focus: the practitioner puts themselves into the pt’s. place, i.e., feelings resonate with one another
¤ An action component: the practitioner asks for feedback to ensure they understand the pt’s. issues & communicates this understanding back to the pt.
¨ Sympathy: emotional identification resulting in the practitioner taking on the emotions of the pt.
¨ Sympathy shares feelings whereas empathy shares understanding (Waite, 2011)
Helen Masin(2011):Matching, Pacing and Leading →↑Rapport
¨ Out of Neurolinguistic Psych: 3 key steps to establish rapport
¨ Matching: subtle modeling of others’ mvmts, posture, breathing, voice
¨ Pacing & leading¤ Bring the pt. along after 1st moving into their world¤ Rapport and trust must be established before the pt.
will follow
8/30/18
28
Mauksch et al, 2008: Relationship, Communication, and Efficiency in the Medical Encounter
¨ “Rapport building such as a warm greeting, eye contact, a brief nonmedical interaction, or checking on an important life event can occur in less than a minute.” (p.1389)
¨ “Empathetic acknowledgment of clues may move the patient to reveal beliefs about illness and treatment preferences that can facilitate creating an effective plan. Providing empathy is intentional and teachable. It my promote pt. self-efficacy without extending visit length.” (p. 1390)
Mauksch 2008
Mauksch, 2008 cont., p. 1390
¨ Examples of clue reading:¤ “It is frustrating when your asthma prevents your from
getting to workӬ Then the empathic response that focuses on the Rx:
¤ “Let’s see how we can improve your symptoms and your ability to keep your job.”
¨ Mauksch says that such empathy ↓riskofpt.feeling discounted and ultimately ↑ quality of care
(similar to motivational interviewing, right?)
8/30/18
29
A Rehab example
¨ Pt. says, “The pain in my right shoulder is there nearly all the time and keeps me up at night. I can’t see how PT will help me get back to work.”
¨ How does the PT reframe this?
¨ How does the PT demonstrate empathy?
Skills to Build Rapport and Increase Empahthetic Response (Coulehan, 2001)
¨ Active listening¤ Non-verbal and paralanguage skills: appropriate positioning and
posture; good eye contact; mirroring of facial expressions; nodding and non-judgmental verbalizations (hmmm, etc); silent and focused
¨ Reflecting the content: “sounds like you are frustrated with….”, or, “If I understand you correctly, you are saying that…”
¨ Identifying and calibrating the emotion: “Tell me how you are feeling about this”, or “I’m not sure I am understanding how you are feeling about this; can you say more?”
Skills to Build Rapport and Increase Empahthetic Response (Coulehan, 2001) Cont.,
¨ Requesting and Accepting Correction: “Did I miss anything?” “Anything you want to add?”¤ Once corrected, reflect back again and identify
emotions
¨ Then pause; the pt. is experiencing being understood…wait to reassure.
8/30/18
30
Words that Work (Coulehan, 2001)
The Ackerman and Hilsenroth TA Review (2003) and Empathy
¨ “The key elements of empathy found in this comprehensive review include:¤ Affirming¤ Helping¤ Warmth/friendliness¤ Understanding”
(p.28)
Rapport and Empathy are linked
¨ Video clip of cartoon and empathyhttps://www.youtube.com/watch?v=1Evwgu369Jw
¨ PTs and PTAs are so good at this! You probably did not need this course!!!!
¨ Go forth and be compassionate!¨ And remember what Donald Berwick said in his Yale
Commencement address: “All that matters is the person” J
8/30/18
31
References¨ Ackerman SJ, Hilsenroth MJ. A Review of Therapist Characteristics & Techniques Positively Impacting the Therapeutic Alliance. Clinical
Psychology Review 23 (2003) 1–33.
¨ Ambady N, Koo J, Rosenthal R, Winograd CH. Physical therapists’ nonverbal communication predicts geriatric patients’ health outcomes. Psychol Aging. 2002;17: 443–452.
¨ Babatunde F, MacDermid J MacIntyre N. Characteristics of therapeutic alliance inmusculoskeletal physiotherapy and occupational therapy practice: a scoping review of theliterature. BMC Health Services Research. 2017; 17:375. Doi 10.1186/s12913-017-2311-3.
¨ Barrett B, Muller D, Rakel D, et al. Placebo, meaning, and health. Perspect Biol Med 2006;49:178–198.
¨ Beattie P, Turner C, Dowda M, et al. The MedRisk Instrument for Measuring Patient Satisfaction With Physical Therapy Care: a psychometric analysis. J Orthop Sports Phys Ther. 2005;35:24 –32.
¨ Beattie PF, Pinto MB, Nelson MK, Nelson R. Patient satisfaction with outpatient physical therapy: instrument validation. Phys Ther. 2002;82:557-565.
¨ Berwick, D. Yale Medical School Graduation Address. May 24, 2010.
¨ Bordin E. The generalizability of the psychoanalytic concept of the working alliance. Psychother.: Theroy Res Pract 1979;16:252-60.
¨ Cavanaugh JT, Konrad SC. Fostering the development of effective person-centered healthcare communication skills: An interprofessionalshared learning model. IOS Press, 2012
¨ CNA Health Pro and HPSO Physical Therapy Liability, 2001-2010, Part 1. www.cna.com & www.hpso.com. Published 1/2012.
¨ Cheing GL, Lai AK, Vong SK, Chan FH. Factorial structure of the Pain Rehabilitation Expectations Scale: a preliminary study. Int J RehabilRes. 2010;33:88 –94.
¨ Coulehan JL, Platt FW, Egener B, et al. “Let me see if I have this right . . . ”:words that help build empathy. Ann Intern Med. 2001;135(3):221-227.
¨ Crane M. Patients who won’t sue their doctors--even when they could. www.medscape.com. November, 2013
¨ Drench ME, Noonan AC, Sharby N, Ventura SH. Psychosocial Aspects of health Care, 3rd ed. Pearson Education Inc., Upper Saddle River NJ, 2012.
¨ Ferreira PH, Ferreira ML, Maher CG, Refshauge KM, Latimer J, Adams RD. The Therapeutic Alliance between Clinicians and Patients Predicts Outcome in Chronic Low Back Pain. Phys Ther;93(4):2013 p470-78.
¨ Fuentes J, Armijo-Olivo S, Funabashi M, Miciak M, Dick B. Enhanced Therapeutic Alliance Modulates Pain Intensity and Muscle Pain Sensitivity in Patients With Chronic Low Back Pain: An Experimental Controlled Study. Phys Ther. 94(4); 2014:477-489.
References cont.¨ Fuertes JN, Mislowack A, Bennett J, Paul L, Gilbert TC, Fontan G, Boylan LS. The Physician-Patient Working Alliance. Patient Educ Couns.
2007 Apr;66(1):29-36.
¨ Gabard DL, Martin MW. Physical Therapy Ethics, 2nd edition. F.A. Davis Co., Philadelphia, 2011.
¨ Greene MG, Adelman R, Charon R, Hoffman S. Ageism in the medical encounter: an exploratory study of the doctor-elderly patient relationship. Lang Commun 1986;6(1-2):113-24.
¨ Greenson RR. Technique and Practice of Psychoanalysis. New York, NY: International Universities Press; 1967
¨ Horvath AO, Symonds BD. Relation between working alliance and outcome in psychotherapy–a meta analysis J Couns Psychol1991;38:139–149.
¨ Hatcher RL, Gillaspy JA. Development and validation of a revised short version of the working alliance inventory. Psychotherapy Res, 16:1:2006,12-25
¨ Hall AM, Ferreira PH, Maher CG, et al. The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: a systematic review. Phys Ther. 2010;90:1099–1110
¨ Hall AM, Ferreira ML, Clemson L, et al. Assessment of the therapeutic alliance in physical rehabilitation: a RASCH analysis. DisabilRehabil. 2012;34:257–266.
¨ Horvath AO. The alliance. Psychotherapy. 2001;38:365-372
¨ Howard KI, Orlinsky DE, Perilstein J. Contribution of therapists to patients' experiences in psychotherapy: a components of variance model for analyzing process data. J Consult Clin Psychol. 1976 Aug;44(4):520-6.
¨ Huntington B, Kuhn N . Communication gaffes: a root cause of malpractice claims. Bayl Univ Med Cent. 16(2); Apr 2003
¨ Hush JM, Cameron K, Mackey M. Patient Satisfaction With Musculoskeletal Physical Therapy Care: A Systematic Review. PHYS THER. 2011; 91:25-36.
¨ Jensen GM, Shepard KF, Hack LM: The novice versus the experienced clinician: insights into the work of the physical therapist, Phys Ther70:314-323, 1990.
¨ Krupnick JL, Sotsky SM, Simmens S, Moyer, J, Elkin I. The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome: Findings in the national institute of mental health treatment of depression collaborative research program. Jnl of Consulting and Clin Psych, 1996;64:532-539.
8/30/18
32
References, cont.¨ Lee J. Johnson, 2011 Good rapport with patients helps lessen lawsuit risk.
http://medicaleconomics.modernmedicine.com/search/solr_search/good%20rapport%20with%20patients%20helps%20lessen%20lawsuits. Accessed 4/10/15.
¨ Levinson W, Roter DL, Mullooly JP, et al: Physician-patient communication: the relationship with malpractice claims among primary care physicians and surgeons, JAMA 277:553-559, 1997.
¨ Luborsky L, McLellan AT, Woody GE, O'Brien CP, Auerbach A. Therapist success and its determinants. Arch Gen Psychiatry. 1985 Jun;42(6):602-11.
¨ Masin H. Communicating to establish rapport and reduce negativity, in Ed, Davis C, Patient practitioner interaction: and experiential manual for developing the art of health care, 5th ed. PP 127-142. 2011. Slack Inc.
¨ Mauksch LB, Dugdale DC, Dodson S, Epstein R. Relationship, Communication, and Efficiency in the Medical Encounter. Arch Intern Med. 2008;168(13):1387-1395
¨ Mehrabian A, Ferris S. Decoding of inconsistent communications. J Pers Soc Psychol. 1967;6:109-114.
¨ Miciak M, et al. The necessary conditions of engagement for the therapeutic relationship inphysiotherapy: an interpretive description study. Archives of physiotherapy. 2018; 8:3.
¨ Perry JF (1975) Nonverbal communication during physical therapy. Physical Therapy 55: 593–600.
¨ Pinto RZ, Ferreira ML, Oliveira VC, Franco MR, Adams R, Maher CG, Ferreira PH. Patient-centred communication is associated with positive therapeutic alliance: a systematic review J Physiother. 2012;58(2):77-87
¨ Purtillo R. Ethical Dimensions in the Health Professions, 4th ed. Elsevier/Saunders, Boston 2005.
¨ Rakel DP. ALTERNATIVE AND COMPLEMENTARY THERAPIES. VOL. 19(5) 2013 247-250.
¨ Takayama T, Yamazaki Y (2004) How breast cancer outpatients perceive mutual participation in patient-physician interactions. Patient Education and Counseling: 52: 279–289.
¨ Thornquist E: Body communication is a continuous process: the first encounter between patient and physiotherapist, Scand J Prim Health Care9:191-196, 1991.
¨ Waite LA. What Is It They Say About Best Intentions? A Life Lesson in Empathy and Sympathy Health Communication, 26: 389–391, 2011
¨ Warren S, Rashiq S, Magee DJ, Gross DP. Enhanced TA Modulates Pain Intensity and Muscle Pain Sensitivity in Patients with chronic Low Back Pain. Phys Ther;94 (4): 2014 p.477-489.
ReferencesforTherapeuticAlliance;AMoralImperativeandJustGoodPractice
¨ AckermanSJ,HilsenrothMJ.AReviewofTherapistCharacteristics&TechniquesPositivelyImpactingtheTherapeuticAlliance.ClinicalPsychologyReview23(2003)1–33.
¨ AmbadyN,KooJ,RosenthalR,WinogradCH.Physicaltherapists’nonverbalcommunicationpredictsgeriatricpatients’healthoutcomes.PsycholAging.2002;17:443–452.
¨ BabatundeF,MacDermidJMacIntyreN.Characteristicsoftherapeuticallianceinmusculoskeletalphysiotherapyandoccupationaltherapypractice:ascopingreviewoftheliterature.BMCHealthServicesResearch.2017;17:375.Doi10.1186/s12913-017-2311-3.
¨ BarrettB,MullerD,RakelD,etal.Placebo,meaning,andhealth.PerspectBiolMed2006;49:178–198.
¨ BeattieP,TurnerC,DowdaM,etal.TheMedRiskInstrumentforMeasuringPatientSatisfactionWithPhysicalTherapyCare:apsychometricanalysis.JOrthopSportsPhysTher.2005;35:24–32.
¨ BeattiePF,PintoMB,NelsonMK,NelsonR.Patientsatisfactionwithoutpatientphysicaltherapy:instrumentvalidation.PhysTher.2002;82:557-565.
¨ Berwick,D.YaleMedicalSchoolGraduationAddress.May24,2010.
¨ BordinE.Thegeneralizabilityofthepsychoanalyticconceptoftheworkingalliance.Psychother.:TheroyResPract1979;16:252-60.
¨ CavanaughJT,KonradSC.Fosteringthedevelopmentofeffectiveperson-centeredhealthcarecommunicationskills:Aninterprofessionalsharedlearningmodel.IOSPress,2012
¨ CNAHealthProandHPSOPhysicalTherapyLiability,2001-2010,Part1.www.cna.com&www.hpso.com.Published1/2012.
¨ CheingGL,LaiAK,VongSK,ChanFH.FactorialstructureofthePainRehabilitationExpectationsScale:apreliminarystudy.IntJRehabilRes.2010;33:88–94.
¨ CoulehanJL,PlattFW,EgenerB,etal.“LetmeseeifIhavethisright...”:wordsthathelpbuildempathy.AnnInternMed.2001;135(3):221-227.
¨ CraneM.Patientswhowon’tsuetheirdoctors--evenwhentheycould.www.medscape.com.November,2013
¨ DrenchME,NoonanAC,SharbyN,VenturaSH.PsychosocialAspectsofhealthCare,3rded.PearsonEducationInc.,UpperSaddleRiverNJ,2012.
¨ FerreiraPH,FerreiraML,MaherCG,RefshaugeKM,LatimerJ,AdamsRD.TheTherapeuticAlliancebetweenCliniciansandPatientsPredictsOutcomeinChronicLowBackPain.PhysTher;93(4):2013p470-78.
¨ FuentesJ,Armijo-OlivoS,FunabashiM,MiciakM,DickB.EnhancedTherapeuticAllianceModulatesPainIntensityandMusclePainSensitivityinPatientsWithChronicLowBackPain:AnExperimentalControlledStudy.PhysTher.94(4);2014:477-489.
¨ FuertesJN,MislowackA,BennettJ,PaulL,GilbertTC,FontanG,BoylanLS.ThePhysician-PatientWorkingAlliance.PatientEducCouns.2007Apr;66(1):29-36.
¨ GabardDL,MartinMW.PhysicalTherapyEthics,2ndedition.F.A.DavisCo.,Philadelphia,2011.
¨ GreeneMG,AdelmanR,CharonR,HoffmanS.Ageisminthemedicalencounter:anexploratorystudyofthedoctor-elderlypatientrelationship.LangCommun1986;6(1-2):113-24.
¨ GreensonRR.TechniqueandPracticeofPsychoanalysis.NewYork,NY:InternationalUniversitiesPress;1967
¨ HorvathAO,SymondsBD.Relationbetweenworkingallianceandoutcomeinpsychotherapy–ametaanalysisJCounsPsychol1991;38:139–149.
¨ HatcherRL,GillaspyJA.Developmentandvalidationofarevisedshortversionoftheworkingallianceinventory.PsychotherapyRes,16:1:2006,12-25
¨ HallAM,FerreiraPH,MaherCG,etal.Theinfluenceofthetherapist-patientrelationshipontreatmentoutcomeinphysicalrehabilitation:asystematicreview.PhysTher.2010;90:1099–1110
¨ HallAM,FerreiraML,ClemsonL,etal.Assessmentofthetherapeuticallianceinphysicalrehabilitation:aRASCHanalysis.DisabilRehabil.2012;34:257–266.
¨ HorvathAO.Thealliance.Psychotherapy.2001;38:365-372
¨ HowardKI,OrlinskyDE,PerilsteinJ.Contributionoftherapiststopatients'experiencesinpsychotherapy:acomponentsofvariancemodelforanalyzingprocessdata.JConsultClinPsychol.1976Aug;44(4):520-6.
¨ HuntingtonB,KuhnN.Communicationgaffes:arootcauseofmalpracticeclaims.BaylUnivMedCent.16(2);Apr2003
¨ HushJM,CameronK,MackeyM.PatientSatisfactionWithMusculoskeletalPhysicalTherapyCare:ASystematicReview.PHYSTHER.2011;91:25-36.
¨ JensenGM,ShepardKF,HackLM:Thenoviceversustheexperiencedclinician:insightsintotheworkofthephysicaltherapist,PhysTher70:314-323,1990.
¨ KrupnickJL,SotskySM,SimmensS,Moyer,J,ElkinI.Theroleofthetherapeuticallianceinpsychotherapyandpharmacotherapyoutcome:Findingsinthenationalinstituteofmentalhealthtreatmentofdepressioncollaborativeresearchprogram.JnlofConsultingandClinPsych,1996;64:532-539.
¨ LeeJ.Johnson,2011Goodrapportwithpatientshelpslessenlawsuitrisk.http://medicaleconomics.modernmedicine.com/search/solr_search/good%20rapport%20with%20patients%20helps%20lessen%20lawsuits.Accessed4/10/15.
¨ LevinsonW,RoterDL,MulloolyJP,etal:Physician-patientcommunication:therelationshipwithmalpracticeclaimsamongprimarycarephysiciansandsurgeons,JAMA277:553-559,1997.
¨ LuborskyL,McLellanAT,WoodyGE,O'BrienCP,AuerbachA.Therapistsuccessanditsdeterminants.ArchGenPsychiatry.1985Jun;42(6):602-11.
¨ MasinH.Communicatingtoestablishrapportandreducenegativity,inEd,DavisC,Patientpractitionerinteraction:andexperientialmanualfordevelopingtheartofhealthcare,5thed.PP127-142.2011.SlackInc.
¨ MaukschLB,DugdaleDC,DodsonS,EpsteinR.Relationship,Communication,andEfficiencyintheMedicalEncounter.ArchInternMed.2008;168(13):1387-1395
¨ MehrabianA,FerrisS.Decodingofinconsistentcommunications.JPersSocPsychol.1967;6:109-114.
¨ MiciakM,etal.Thenecessaryconditionsofengagementforthetherapeuticrelationshipinphysiotherapy:aninterpretivedescriptionstudy.Archivesofphysiotherapy.2018;8:3.
¨ PerryJF(1975)Nonverbalcommunicationduringphysicaltherapy.PhysicalTherapy55:593–600.
¨ PintoRZ,FerreiraML,OliveiraVC,FrancoMR,AdamsR,MaherCG,FerreiraPH.Patient-centredcommunicationisassociatedwithpositivetherapeuticalliance:asystematicreviewJPhysiother.2012;58(2):77-87
¨ PurtilloR.EthicalDimensionsintheHealthProfessions,4thed.Elsevier/Saunders,Boston2005.
¨ RakelDP.ALTERNATIVEANDCOMPLEMENTARYTHERAPIES.VOL.19(5)2013247-250.
¨ TakayamaT,YamazakiY(2004)Howbreastcanceroutpatientsperceivemutualparticipationinpatient-physicianinteractions.PatientEducationandCounseling:52:279–289.
¨ ThornquistE:Bodycommunicationisacontinuousprocess:thefirstencounterbetweenpatientandphysiotherapist,ScandJPrimHealthCare9:191-196,1991.
¨ WaiteLA.WhatIsItTheySayAboutBestIntentions?ALifeLessoninEmpathyandSympathyHealthCommunication,26:389–391,2011
JillS.Boissonnault,2018
Code of Ethics for the Physical TherapistHOD S06-09-07-12 [Amended HOD S06-00-12-23; HOD 06-91-05-05;HOD 06-87-11-17; HOD 06-81-06-18; HOD 06-78-06-08; HOD 06-78-06-07; HOD 06-77-18-30; HOD 06-77-17-27; Initial HOD 06-73-13-24] [Standard]
Preamble The Code of Ethics for the Physical Therapist (Code of Ethics) delineates the ethical obligations of all physical therapists as determined by the House of Delegates of the American Physical Therapy Association (APTA). The purposes of this Code of Ethics are to: 1. Define the ethical principles that form the foundation of physical therapist practice in patient/client management, consultation, edu-
cation, research, and administration. 2. Provide standards of behavior and performance that form the basis of professional accountability to the public. 3. Provide guidance for physical therapists facing ethical challenges, regardless of their professional roles and responsibilities. 4. Educate physical therapists, students, other health care professionals, regulators, and the public regarding the core values, ethical prin-
ciples, and standards that guide the professional conduct of the physical therapist. 5. Establish the standards by which the American Physical Therapy Association can determine if a physical therapist has engaged in
unethical conduct. No code of ethics is exhaustive nor can it address every situation. Physical therapists are encouraged to seek additional advice or consulta-tion in instances where the guidance of the Code of Ethics may not be definitive. This Code of Ethics is built upon the five roles of the physical therapist (management of patients/clients, consultation, education, research, and administration), the core values of the profession, and the multiple realms of ethical action (individual, organizational, and societal). Physical therapist practice is guided by a set of seven core values: accountability, altruism, compassion/caring, excellence, integrity, profes-sional duty, and social responsibility. Throughout the document the primary core values that support specific principles are indicated in parentheses. Unless a specific role is indicated in the principle, the duties and obligations being delineated pertain to the five roles of the physical therapist. Fundamental to the Code of Ethics is the special obligation of physical therapists to empower, educate, and enable those with impairments, activity limitations, participation restrictions, and disabilities to facilitate greater independence, health, wellness, and enhanced quality of life.
PrinciplesPrinciple #1: Physical therapists shall respect the
inherent dignity and rights of all individuals. (Core Values: Compassion, Integrity)
1A. Physical therapists shall act in a respectful manner toward each person regardless of age, gender, race, nationality, reli-gion, ethnicity, social or economic status, sexual orientation, health condition, or disability.
1B. Physical therapists shall recognize their personal biases and shall not discriminate against others in physical therapist prac-tice, consultation, education, research, and administration.
Principle #2: Physical therapists shall be trustworthy and compassionate in addressing the rights and needs of patients/clients.
(Core Values: Altruism, Compassion, Professional Duty)
2A. Physical therapists shall adhere to the core values of the pro-fession and shall act in the best interests of patients/clients over the interests of the physical therapist.
2B. Physical therapists shall provide physical therapy services with compassionate and caring behaviors that incorporate the individual and cultural differences of patients/clients.
2C. Physical therapists shall provide the information necessary to allow patients or their surrogates to make informed deci-sions about physical therapy care or participation in clinical research.
2D. Physical therapists shall collaborate with patients/clients to empower them in decisions about their health care.
2E. Physical therapists shall protect confidential patient/client information and may disclose confidential informa-tion to appropriate authorities only when allowed or as required by law.
Principle #3: Physical therapists shall be accountable for making sound professional judgments.
(Core Values: Excellence, Integrity)
3A. Physical therapists shall demonstrate independent and objec-tive professional judgment in the patient’s/client’s best interest in all practice settings.
3B. Physical therapists shall demonstrate professional judgment informed by professional standards, evidence (including current literature and established best practice), practitioner experience, and patient/client values.
3C. Physical therapists shall make judgments within their scope of practice and level of expertise and shall communicate with, collaborate with, or refer to peers or other health care profes-sionals when necessary.
3D. Physical therapists shall not engage in conflicts of interest that interfere with professional judgment.
3E. Physical therapists shall provide appropriate direction of and communication with physical therapist assistants and support personnel.
Principle #4: Physical therapists shall demonstrate integrity in their relationships with patients/clients, families, colleagues, students, research partici-pants, other health care providers, employers, payers, and the public.
(Core Value: Integrity)
4A. Physical therapists shall provide truthful, accurate, and rel-evant information and shall not make misleading represen-tations.
4B. Physical therapists shall not exploit persons over whom they have supervisory, evaluative or other authority (eg, patients/clients, students, supervisees, research participants, or employees).
4C. Physical therapists shall discourage misconduct by health care professionals and report illegal or unethical acts to the relevant authority, when appropriate.
4D. Physical therapists shall report suspected cases of abuse involving children or vulnerable adults to the appropriate authority, subject to law.
4E. Physical therapists shall not engage in any sexual relation-ship with any of their patients/clients, supervisees, or students.
4F. Physical therapists shall not harass anyone verbally, physi-cally, emotionally, or sexually.
Principle #5: Physical therapists shall fulfill their legal and professional obligations.
(Core Values: Professional Duty, Accountability)
5A. Physical therapists shall comply with applicable local, state, and federal laws and regulations.
5B. Physical therapists shall have primary responsibility for supervision of physical therapist assistants and support personnel.
5C. Physical therapists involved in research shall abide by accepted standards governing protection of research participants.
5D. Physical therapists shall encourage colleagues with physical, psychological, or substance-related impairments that may adversely impact their professional responsibilities to seek assistance or counsel.
5E. Physical therapists who have knowledge that a colleague is unable to perform their professional responsibilities with reasonable skill and safety shall report this information to the appropriate authority.
5F. Physical therapists shall provide notice and information about alternatives for obtaining care in the event the physi-cal therapist terminates the provider relationship while the patient/client continues to need physical therapy services.
Principle #6: Physical therapists shall enhance their expertise through the lifelong acquisition and refinement of knowledge, skills, abilities, and professional behaviors.
(Core Value: Excellence)
6A. Physical therapists shall achieve and maintain professional competence.
6B. Physical therapists shall take responsibility for their profes-sional development based on critical self-assessment and reflection on changes in physical therapist practice, educa-tion, health care delivery, and technology.
6C. Physical therapists shall evaluate the strength of evidence and applicability of content presented during professional development activities before integrating the content or techniques into practice.
6D. Physical therapists shall cultivate practice environments that support professional development, lifelong learning, and excellence.
Principle #7: Physical therapists shall promote organizational behaviors and business practices that benefit patients/clients and society.
(Core Values: Integrity, Accountability)
7A. Physical therapists shall promote practice environments that support autonomous and accountable professional judgments.
7B. Physical therapists shall seek remuneration as is deserved and reasonable for physical therapist services.
7C. Physical therapists shall not accept gifts or other consider-ations that influence or give an appearance of influencing their professional judgment.
7D. Physical therapists shall fully disclose any financial interest they have in products or services that they recommend to patients/clients.
7E. Physical therapists shall be aware of charges and shall ensure that documentation and coding for physical therapy ser-vices accurately reflect the nature and extent of the services provided.
7F. Physical therapists shall refrain from employment arrange-ments, or other arrangements, that prevent physical thera-pists from fulfilling professional obligations to patients/clients.
Principle #8: Physical therapists shall participate in efforts to meet the health needs of people locally, nationally, or globally.
(Core Value: Social Responsibility)
8A. Physical therapists shall provide pro bono physical therapy services or support organizations that meet the health needs of people who are economically disadvantaged, unin-sured, and underinsured.
8B. Physical therapists shall advocate to reduce health dispari-ties and health care inequities, improve access to health care services, and address the health, wellness, and preventive health care needs of people.
8C. Physical therapists shall be responsible stewards of health care resources and shall avoid overutilization or under-utilization of physical therapy services.
8D. Physical therapists shall educate members of the public about the benefits of physical therapy and the unique role of the physical therapist.
Standards of Ethical Conduct for the Physical Therapist AssistantHOD S06-09-20-18 [Amended HOD S06-00-13-24; HOD 06-91-06-07; Initial HOD 06-82-04-08] [Standard]
Preamble The Standards of Ethical Conduct for the Physical Therapist Assistant (Standards of Ethical Conduct) delineate the ethical obligations of all physical therapist assistants as determined by the House of Delegates of the American Physical Therapy Association (APTA). The Standards of Ethical Conduct provide a foundation for conduct to which all physical therapist assistants shall adhere. Fundamental to the Standards of Ethical Conduct is the special obligation of physical therapist assistants to enable patients/clients to achieve greater indepen-dence, health and wellness, and enhanced quality of life.
No document that delineates ethical standards can address every situation. Physical therapist assistants are encouraged to seek additional advice or consultation in instances where the guidance of the Standards of Ethical Conduct may not be definitive.
Standards Standard #1: Physical therapist assistants shall
respect the inherent dignity, and rights, of all individuals.
1A. Physical therapist assistants shall act in a respectful manner toward each person regardless of age, gender, race, nationality, religion, ethnicity, social or economic status, sexual orienta-tion, health condition, or disability.
1B. Physical therapist assistants shall recognize their personal bi-ases and shall not discriminate against others in the provision of physical therapy services.
Standard #2: Physical therapist assistants shall be trustworthy and compassionate in addressing the rights and needs of patients/clients.
2A. Physical therapist assistants shall act in the best interests of patients/clients over the interests of the physical therapist as-sistant.
2B. Physical therapist assistants shall provide physical therapy interventions with compassionate and caring behaviors that incorporate the individual and cultural differences of pa-tients/clients.
2C. Physical therapist assistants shall provide patients/clients with information regarding the interventions they provide.
2D. Physical therapist assistants shall protect confidential patient/client information and, in collaboration with the physical therapist, may disclose confidential information to appropri-ate authorities only when allowed or as required by law.
Standard #3: Physical therapist assistants shall make sound decisions in collaboration with the physical therapist and within the boundaries established by laws and regulations.
3A. Physical therapist assistants shall make objective decisions in the patient’s/client’s best interest in all practice settings.
3B. Physical therapist assistants shall be guided by information about best practice regarding physical therapy interventions.
3C. Physical therapist assistants shall make decisions based upon their level of competence and consistent with patient/client values.
3D. Physical therapist assistants shall not engage in conflicts of interest that interfere with making sound decisions.
3E. Physical therapist assistants shall provide physical therapy ser-vices under the direction and supervision of a physical thera-pist and shall communicate with the physical therapist when patient/client status requires modifications to the established plan of care.
Standard #4: Physical therapist assistants shall dem-onstrate integrity in their relationships with patients/clients, families, colleagues, students, other health care providers, employers, payers, and the public.
4A. Physical therapist assistants shall provide truthful, accurate, and relevant information and shall not make misleading representations.
4B. Physical therapist assistants shall not exploit persons over whom they have supervisory, evaluative or other authority (eg, patients/clients, students, supervisees, research partici-pants, or employees).
4C. Physical therapist assistants shall discourage misconduct by health care professionals and report illegal or unethical acts to the relevant authority, when appropriate.
4D. Physical therapist assistants shall report suspected cases of abuse involving children or vulnerable adults to the su-pervising physical therapist and the appropriate authority, subject to law.
4E. Physical therapist assistants shall not engage in any sexual relationship with any of their patients/clients, supervisees, or students.
4F. Physical therapist assistants shall not harass anyone verbally, physically, emotionally, or sexually.
Standard #5: Physical therapist assistants shall fulfill their legal and ethical obligations.
5A. Physical therapist assistants shall comply with applicable local, state, and federal laws and regulations.
5B. Physical therapist assistants shall support the supervisory role of the physical therapist to ensure quality care and promote patient/client safety.
5C. Physical therapist assistants involved in research shall abide by accepted standards governing protection of research partici-pants.
5D. Physical therapist assistants shall encourage colleagues with physical, psychological, or substance-related impairments that may adversely impact their professional responsibilities to seek assistance or counsel.
5E. Physical therapist assistants who have knowledge that a col-league is unable to perform their professional responsibilities with reasonable skill and safety shall report this information to the appropriate authority.
Standard #6: Physical therapist assistants shall enhance their competence through the lifelong acquisition and refinement of knowledge, skills, and abilities.
6A. Physical therapist assistants shall achieve and maintain clinical competence.
6B. Physical therapist assistants shall engage in lifelong learning consistent with changes in their roles and responsibilities and advances in the practice of physical therapy.
6C. Physical therapist assistants shall support practice environ-ments that support career development and lifelong learning.
Standard #7: Physical therapist assistants shall sup-port organizational behaviors and business prac-tices that benefit patients/clients and society.
7A. Physical therapist assistants shall promote work environments that support ethical and accountable decision-making.
7B. Physical therapist assistants shall not accept gifts or other con-siderations that influence or give an appearance of influencing their decisions.
7C. Physical therapist assistants shall fully disclose any financial in-terest they have in products or services that they recommend to patients/clients.
7D. Physical therapist assistants shall ensure that documenta-tion for their interventions accurately reflects the nature and extent of the services provided.
7E. Physical therapist assistants shall refrain from employment arrangements, or other arrangements, that prevent physi-cal therapist assistants from fulfilling ethical obligations to patients/clients
Standard #8: Physical therapist assistants shall participate in efforts to meet the health needs of people locally, nationally, or globally.
8A. Physical therapist assistants shall support organizations that meet the health needs of people who are economically disadvantaged, uninsured, and underinsured.
8B. Physical therapist assistants shall advocate for people with impairments, activity limitations, participation restrictions, and disabilities in order to promote their participation in community and society.
8C. Physical therapist assistants shall be responsible stewards of health care resources by collaborating with physical therapists in order to avoid overutilization or underutiliza-tion of physical therapy services.
8D. Physical therapist assistants shall educate members of the public about the benefits of physical therapy.
Working Alliance Inventory
Short Form (C)
Instructions
! On the following pages there are sentences that describe some of the different ways a person might think or feel about his or her therapist (counsellor). As you read the sentences mentally insert the name of your therapist (counselor) in place of _____________in the text.
Below each statement inside there is a seven point scale:
!1! 2! 3! 4! 5! 6! 7Never! Rarely! Occasionally! Sometimes! Often! Very Often! Always!
! If the statement describes the way you always feel (or think) circle the number 7; if it never ap-plies to you circle the number 1. Use the numbers in between to describe the variations between these extremes.
This questionnaire is CONFIDENTIAL; neither your therapist nor the agency will see your answers.
! Work fast, your first impressions are the ones we would like to see. (PLEASE DON'T FORGET TO RESPOND TO EVERY ITEM.)
Thank you for your cooperation.
© A. O. Horvath, 1981, 1982; Revision Tracey & Kokotowitc 1989.
!! 1.! _______________ and I agree about the things I will need to do in therapy to help improve my situation.
1! 2! 3! 4! 5! 6! 7Never! Rarely! Occasionally! Sometimes! Often! Very Often! Always
! 2.! What I am doing in therapy gives me new ways of looking at my problem.1! 2! 3! 4! 5! 6! 7
Never! Rarely! Occasionally! Sometimes! Often! Very Often! Always
! 3.! I believe _______________ likes me.1! 2! 3! 4! 5! 6! 7
Never! Rarely! Occasionally! Sometimes! Often! Very Often! Always
! 4.! _______________ does not understand what I am trying to accomplish in therapy.1! 2! 3! 4! 5! 6! 7
Never! Rarely! Occasionally! Sometimes! Often! Very Often! Always
! 5.! I am confident in _______________ 's ability to help me.1! 2! 3! 4! 5! 6! 7
Never! Rarely! Occasionally! Sometimes! Often! Very Often! Always!
! 6.! _______________ and I are working towards mutually agreed upon goals.1! 2! 3! 4! 5! 6! 7
Never! Rarely! Occasionally! Sometimes! Often! Very Often! Always
! 7.! I feel that _______________ appreciates me.1! 2! 3! 4! 5! 6! 7
Never! Rarely! Occasionally! Sometimes! Often! Very Often! Always
! 8.! We agree on what is important for me to work on.1! 2! 3! 4! 5! 6! 7
Never! Rarely! Occasionally! Sometimes! Often! Very Often! Always
! 9.! _______________ and I trust one another.1! 2! 3! 4! 5! 6! 7
Never! Rarely! Occasionally! Sometimes! Often! Very Often! Always
! 10.! _______________ and I have different ideas on what my problems are.1! 2! 3! 4! 5! 6! 7
Never! Rarely! Occasionally! Sometimes! Often! Very Often! Always
! 11.! We have established a good understanding of the kind of changes that would be good for me.1! 2! 3! 4! 5! 6! 7
Never! Rarely! Occasionally! Sometimes! Often! Very Often! Always
! 12.! I believe the way we are working with my problem is correct.1! 2! 3! 4! 5! 6! 7
Never! Rarely! Occasionally! Sometimes! Often! Very Often! Always
!
Scoring key for the WAI Short form (C)
Task scale items:! ! 1,! 2,! 8,! 12.
Direction* of scoring:! +! +! +! +
Bond scale items:! ! 3,! 5,! 7,! 9.
Direction* of scoring:! +! +! +! +
Goal scale items:! ! 4,! 6,! 10,! 11.
Direction* of scoring:! -! +! -! +
* Items marked positive (+) -> high values are better alliance; otherwise (-) re-verse scoring.
Boissonnault, William Communication Seminar Excerpts
Obstacles to Achieving Positive Initial Experience: Patient Factors
Patient lack of knowledge-why are they coming to therapy?
Patient lack of respect for therapy, in general
Poor patient motivation
Patient’s current emotional state; angry, depressed, frustrated
Patient level of education, or lack of
Patient is poor historian, talkative, confused state, fearful
Patient “after” secondary gain
Patient ethnicity, cultural beliefs/traditions
Patient’s family dynamics
Family member present for the visit-dominates
Past experiences with therapy-negative, or just different than current care provided
Patient has a different agenda than the therapist’s
Patient self-administered forms/questionnaires “left blank”
Involved in litigation or workers’ compensation systems
Hasn’t accepted diagnosis
Obstacles to Achieving Positive Initial Experience: Therapist Factors
Lack of time
Lack of knowledge/skills
Lack of confidence because of the lack of knowledge/skills
Age/experience-or the “lack of” (patient/perception-therapist appears “too young”)
Therapist state-of-well-being-fatigued, been a bad day
Therapist personality doesn’t “click” with patient’s or family’s
Lack of continuity/consistency between therapists if more than one involved
Lack of written communication skills
Obstacles to Achieving Positive Initial Experience: Environmental Factors
Patients are late-needed directions/parking information
Inadequate medical history of patient-social/diagnosis information available prior to the
interview
Environment not conducive to effective interchange-noisy, lack of privacy, interruptions
Lack of equipment/supplies in the department, on floor
Mode of required or chosen documentation-may not be efficient
Patient lack of comfort-physical and/or general-maybe related to patient/therapist
gender, age, cultural differences
William Boissonnault, PT, DPT, DHSc, FAAOMPT, FAPTA
Strategies to Develop Rapport QUICKLY!!
Setting the Environment
o Patient knows how to get to the clinic, parking, what clothes to bring etc., prior to the initial visit
(front desk staff)
o Patient in comfortable position
o Patient in their clothing until physical exam
o If patient in a gown-properly draped
o Minimize interruptions-work with front desk-phone calls, make sure each room properly
equipped (e.g. goniometers, reflex hammers, linen)
o Well-lit room, but able to adjust lights if necessary
o Privacy
o Become familiar with patient history before start the interview (review medical record, other
HCP notes, self-administered questionnaires)
o Therapist be on time! If running behind let the patient know.
Non-Verbal
o Gentle touch (e.g. hand shake, “guide into room”, monitor patient response-is it positive or not!)
o Therapist position (appropriate distance, facing patient and eye level if possible)
o Therapist dress and hygiene
o Facial expressions
o Eye contact
o Nodding and gestures
o Watching the watch
o Entry into room/booth-calm demeanor
o Awareness of cultural factors
Verbal
o Therapist introduction (name and physical therapist)
o Patient introduction-start more formal and then can ask how they would like to be addressed
o Have you had PT before?
o Discuss plan for visit (“ground rules”)-then ask patient “does this sound reasonable?”
o Quality of voice (tone, volume, speed, etc.)
o Ice breaker-did you find your way here ok, Was it difficult driving here, have you been here
before…..etc.)
o Start with open-ended question-related to the purpose of the visit, then get more directed with
questions-based on information you need to make your decisions
o Allow patient to finish response, don’t finish the response for the patient
o Use pauses and silence effectively
o Use appropriate terminology, avoid medical jargon, unless the patient is a HCP
o Restating and paraphrasing as a way to summarize-patient can add clarification if necessary, if
not needed patient “feels” they have been heard
o Clarify/confirm patient’s goals for therapy