The Therapeutic Alliance: How Important is Trust?

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Although it may have not always been the case, we now accept that trust between patient and health practitioner can greatly impact how a patient perceives the quality of their treatment and the clinical outcomes. This is potentially as true for chiropractors and the people under they care for as it is for other health practitioners. It may feel like a given in today’s approach to healthcare, but how is this trust built? Why do we ‘click’ with some practitioners and not others? What is it about their interaction that sways us one way or the other? A recent study attempts to shed some light on these queries, and hopefully allow us to foster more trusting patient and practitioner relationships.

It could be said that chiropractic practices run on trust: we place our spines, nervous systems and that of our families in the hands of people whose qualifications we trust, but whose execution of the manoeuvres, techniques and adjustments is detrimental to health. While chiropractic care has an excellent and even exemplary safety record, it is trust that allows a person to relax on the adjusting table and let the chiropractor do what they do best. It is also trust that allows individuals under care to trust their chiropractor with the non-musculoskeletal details of the stresses and strains that impact on and emerge out of their nervous systems.

The study, which appeared in the Journal of the Canadian Chiropractic Association (referenced below) interviewed chiropractors to gather information on which aspects chiropractors found important in building trust. The results were perhaps unsurprising. The key factors included: honesty, communication, perceived competence and caring. It is interesting to note that only one of the four factors had to do with the skill of the practitioner. The rest is in the relational aspects of care. How connected and in tune we are with our patients?

It has been suggested that a “therapeutic alliance provides the central foundation for patients to receive the benefits from other contextual factors and their placebo effects, further improving health related outcomes.” The authors of the study also remarked that:

“Trust affects patient behavior and attitudes, including willingness to seek care, return for subsequent episodes of care, divulge sensitive information, and adhere to a plan of management. Trust in physicians has been shown to correlate positively with adherence to treatment recommendations, willingness to recommend a physician to others, perceived effectiveness of care, improvement in self-reported health, staying under the care of the same physician, and avoiding seeking second opinions. Patients with high levels of trust in their healthcare providers report more beneficial health behaviours, fewer symptoms, a higher quality of life, and greater satisfaction with treatment.”

“Trust has been positively correlated with satisfaction; therefore, a trusting therapeutic alliance may foster patient satisfaction and may improve the patient experience with their healthcare practitioner.”

THE STUDY

The study took place in two phases: interviews with chiropractors and online surveys. Interestingly, the surveys didn’t cover how long chiropractors spend on patient interactions whereas the interviews featured this as an important theme.

The interviews were conducted with six chiropractors from College of Chiropractors of British Columbia and were recruited via convenience sampling. The selection was based on their commitment to research as indicated by their involvement in Vancouver Chiropractic Practice-Based Research Network. All twenty-five members were invited to participate via email. Of this group, eight responded and six were interviewed.

The interviews were one-on-one and were conducted in private in-person or on skype. They went from 30-60 minutes and were recorded, transcribed, and analysed. The questions were centred around honesty, competence, fidelity, and confidentiality. They started as a broad conversation about the themes and then narrowed onto the themes as the interview went on. Open-ended questions were also included to allow for unexpected findings or answers.

The survey aspect was conducted online and was the first survey constructed to assess factors of perceived patient trust amongst chiropractors. As mentioned before, four themes were predominant from the interviews; honesty, communication, perceived competence, and caring. It was also found that previous chiropractic experience, friends and family, and CA staff can all influence a patient’s trust.

Honesty:

Participants suggested that a trusting relationship could be formed more quickly if they admit to mistakes and acknowledge their limitations (potentially resulting in a referral). The study also found that chiropractors giving realistic prognosis information or feedback regardless of severity was important, as well as being gentle when discussing points of conflict with patients.

Interestingly, the study’s participants believed that patients could tell when they were not being honest and that this could be detrimental to the relationship. Authenticity was highlighted as a subcategory of honesty through-out the study process. Participants believed that when chiropractors are authentic, they have greater success in developing trust with patients and showing genuine interest helps build rapport with patients. They mentioned that “trying to exist at a human level with them”, would build trust. When asked about characteristics of an authentic chiropractor, one response was: “I think they’re very direct. I think they’re not afraid to be themselves. So, they’re staying human.”

Communication:

An importance was placed on listening to patients, without interrupting, and setting clear expectations. “Uninterrupted listening provides an opportunity for patients to feel engaged and was described as a method of forming meaningful connection.” One interviewee said, “Making some sort of connection that’s other than their healthcare” was important.

One finding that may prove truthful to the point of amusing, was that CA’s warning patients when their chiropractor was running late helps patients manage their expectations. It was listed alongside nonverbal communication and discretion when it comes to physical touch. Using a ‘mirror’ technique for communication (i.e. using the patient’s body language as a guide for their comfort level) could be of assistance.

Perceived Competence:

While competence certainly comes in the form of qualification and registration with the relevant authorities, the study also found that it also included interpersonal skills, cognitive skills, ethics, and appearance. Participants believed that competence was demonstrated in the ways of professional attire online reviews or in-person recommendations, booking difficulties, and clinical outcomes.

Perceived competence is also most likely influenced by a chiropractor’s ability to effectively communicate with and educate their patients. Some found it was easier to build trust with those who had seen a chiro previously and some found that it was more difficult.

Caring:

“Many of our interviewees identified that patients can be vulnerable and that demonstrating empathy and placing patient needs above self-serving motives help establish trust.” Therefore, a genuine interest in the patient’s wellbeing and avoiding or disclosing conflicts of interest was found to be significant. It was important to avoid aggressively marketing products or engaging in coercive marketing tactics, and that the easiest way to avoid this was to suggest products out of patient need rather than a financial motivation.

A potentially tricky topic was that of fee structures. Thus, it was listed among the ‘caring’ aspect of the study. A repetitive finding was the importance of ensuring fee structures are considerate of individuals who may have financial difficulties. “Participants mentioned that chiropractors can demonstrate a caring demeanor by offering tea or water in their waiting rooms, hiring and training friendly staff, and collaborating with other healthcare professionals.”

While there is plenty of room for more study when it comes to the ways in which patients actually feel about the therapeutic alliance. This study only covered the chiropractor’s perceptions. So perhaps that’s a story for another day, but in the meantime, this paper provides a number of tangible and intangible ways in which chiropractors can improve the way they build the all-important therapeutic alliance.

Reference:

  1. Connell G, Bainbridge L. Understanding how chiropractors build trust with patients: a mixed-methods study. The Journal of the Canadian Chiropractic Association. 2020. 64(2):97–108. 

 

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