Therapeutic Relationships

We develop relationships every day with patients, patient’s families, colleagues, and friends. Increasingly, research shows that effective therapeutic relationships play an important role in positive patient outcomes, making these relationships critically important.¹

But what is the difference between a personal relationship and a professional relationship?

When the distinction gets blurry, what can physiotherapists do to ensure that they don’t cross boundaries and find themselves in a challenging situation?

Q: I live in a small community, and have known most of my patients since I was a child. Many have been coming to my clinic on and off for years. At this point they feel like old friends. That’s a good thing, right?

A: While it is a good thing to have a positive relationship with your patient, physiotherapists must recognize that there are risks to having personal and professional relationships with a patient at the same time, including privacy concerns, communication considerations, the challenge of maintaining professional objectivity, and the risk of blurring the boundary between personal and professional relationships.

Although it seems obvious that there are differences between these types of relationships, problems arise when health-care providers fail to maintain the distinctions.

The table below focuses on the different aspects of personal and professional relationships. By focusing on the differences, physiotherapists may have an easier time identifying when they are, or are not, maintaining healthy boundaries between themselves and their patients.

Aspect of the Relationship	Professional Relationship	Personal Relationship
Money	Physiotherapist receives financial compensation for patient care.	Shared
Duration	Limited to the duration of treatment.	No limit, may be lifelong
Location	Limited to the treatment location.	No restriction, anywhere
Purpose	To provide physiotherapy services to the patient.	Pleasure
Structure	Organized around the provision of physiotherapy services.	Unstructured
Balance of Power	Unequal. The physiotherapist is in a position of power, having more knowledge, influence, and access to private information.	Shared
Responsibility for the Relationship	The physiotherapist is primarily responsible to establish and maintain the professional relationship.	Shared
Preparation for the Relationship	The physiotherapist offers their training and experience and the patient places their trust in this.	Equal

Founding principles

The following principles underlie all therapeutic relationships:

Duty of Care (fiduciary duty): the foundation for all therapeutic relationships is the duty to act in the patient’s interests.

Power is always held by the physiotherapist due to their unique knowledge and skills, access to the patient’s private information, and the patient’s reliance on them for care. Physiotherapists must keep this imbalance in mind and strive to equalize the balance of power in their patient relationships.

Respect for the patient’s beliefs, values and morals is required to develop a therapeutic relationship. This does not require that the physiotherapist adopts or even agrees with the patient’s views, but the physiotherapist must accept the patient’s perspective and ensure that their own values and beliefs do not negatively impact on the quality of care they provide.³

Trust between a patient and their physiotherapist is essential. If a physiotherapist does not use their skills and abilities to address the patient’s needs and act in their best interests, a loss of trust will occur.

Sensitivity is needed to protect the trust and respect of the therapeutic relationship. A patient’s sense of vulnerability may be increased by the physical proximity, varying degrees of undress and personal disclosure inherent in physiotherapy practice.  

“…it took so long to realize that it was I, myself ,who was probably the main variable in outcomes—not the techniques.” David Butler⁴

Benefits of an effective therapeutic relationship

Effective therapeutic relationships lead to increased patient satisfaction, better patient adherence to treatment plans, and improved function and mood.⁴ In some cases, an effective therapeutic relationship has been shown to impact patient-reported pain and other outcomes independent of the treatment provided.¹ Some may argue that this impact represents a placebo effect, while others suggest that this finding supports the critical importance of an effective therapeutic relationship.  

Regardless, the impact of effective patient-provider relationships cannot be ignored.

Setting the stage for a therapeutic relationship

Simple actions can help establish therapeutic relationships and appropriate boundaries:

• Introduce yourself using the NOD (Name, Occupation, Duty) approach (“Hello, I’m Jane Smith. I am the physiotherapist who will be seeing you about your back pain”).⁵
• Intentionally approach the patient as an equal. This includes how you greet the patient, how you position yourself during the patient interview4 and using plain language to explain what you are doing.⁶
• Listen. Be attentive to and address the patient’s concerns.⁴
• Informed consent always starts with a conversation about the patient’s concerns, the proposed treatment, and the risks and benefits of the proposed treatment.⁷
• Validate the patient and individualize your approach to address their unique needs.⁴
• Earn and maintain trust by protecting patient confidentiality and the privacy of patient information.

“Maintain your enthusiasm by viewing the patient through the lens of the individual vs. the lens of the injury.”⁴

A universal precaution

“As many as one third [33%] of women and 14% of men are survivors of childhood sexual abuse… This means that all health-care practitioners – whether they know it or not – encounter adult survivors of interpersonal violence in their practices.”⁸

All health-care providers need to adopt “universal precautions” to ensure that they do not re-victimize these patients in the course of providing care.

Sensitive practice universal precautions:⁸

• Investing adequate time to develop rapport with the patient.
• Letting patients know they can bring someone with them to their treatments.
• Explaining what the subjective and objective assessment involves before proceeding.
• Providing the patient with the opportunity to ask and have questions answered before proceeding.
• Completing the subjective exam before asking the patient to remove their clothing for the objective exam.
• Ensuring privacy for undressing and dressing.
• Re-visiting consent as the assessment and treatment progresses.

The physiotherapist may not ever become aware of the patient’s vulnerability. By demonstrating sensitive practice to all patients, you can decrease the likelihood of inadvertently re-traumatizing survivors of abuse.⁸

Culturally aware care

Canada’s multicultural society is often celebrated, but this diversity can also create challenges in the health-care environment.

For example, conflict may arise from differences in cultural norms and expectations related to:

• Receiving care from a health provider of the opposite sex.
• Gift giving between patients and providers.
• The role of family in health care.
• Disrobing to receive care.

Culture is “learned, shared, (and) transmitted inter-generationally, and reflected in a group’s values, beliefs, norms, practices, patterns of communication, familial roles, and other social regularities.”⁹ The culture of any group “may be directly or indirectly associated with the health-related priorities, decisions, behaviours, and or acceptance and adoption of health education and health communication programs and messages.”⁹

Patient-centered care includes the patient’s values, preferences, and expressed needs and includes the involvement of friends and family in patient care.¹⁰ All these factors are influenced by the patient’s culture; therefore, culture is an important aspect of patient-centered care.

Understanding the culture of a group allows health care and communication to be customized to better address the needs of the group;⁹ however, it is impractical for any one clinician to become familiar with all of the cultures that they encounter in daily practice. “Additionally, viewing patients as members of ethnic or cultural groups, rather than as individuals… might lead providers to stereotype patients and make inappropriate assumptions about their beliefs and behaviors.”¹⁰

What’s a clinician to do?¹⁰

• Acknowledge and reflect upon your own culture. Realize that both patient and provider bring their culture to the relationship.
• Respect the legitimacy of patient’s health beliefs.
• Apply a bio psycho social approach to health care.
• Encourage the patient to discuss their explanations of their illness and its perceived causes (the patient’s explanatory model of illness).
• Discuss your understanding of their illness and its perceived causes, in patient friendly language (the clinician’s explanatory model of illness).
• Negotiate an understanding and a safe, effective and mutually agreeable treatment plan.

Exhibiting these behaviours will help to develop effective therapeutic relationships with patients who are members of different cultural groups.

“The clinician’s responsibility to monitor and respond to the client’s verbal and non-verbal communication cannot be overstated… the onus of ensuring the client’s consent is truly ongoing is on the clinician.”8

Defining professional boundaries

Professional boundaries set limits to define the parameters of a safe, therapeutic connection between physiotherapists and their patients. Rather than a clear, consistent dividing line, physiotherapists must be aware of the grey zone which lies in between clearly acceptable and clearly unacceptable behavior. In this zone, behavior may or may not be appropriate depending on aspects of the patient-provider relationship and the treatment provided. In this way, professional boundaries are dynamic in nature.

Inherent to establishing therapeutic relationships is knowing where to draw the line between a professional relationship and a personal one, and how to avoid crossing that line.

To do so, you must acknowledge:

• The power imbalance inherent in the relationship.
• The profession’s expectations for appropriate behavior.
• Your duty of care.

Blurring the line

Given that there is a grey zone of behaviours that may or may not be appropriate, it can sometimes be difficult to know if you have crossed the line.

May be appropriate	Probably not appropriate	Never apporpriate
Giving or accepting gifts.	Social relationships with current patients.	Physical, verbal, sexual or emotional abuse.
Romantic relationships with former patients.	Treating family or friends.	Sexual relationships with a current patient.
Hugging/touching for non-treatment reasons.

Warning signs for boundary crossings

“The crossing of boundaries usually begins with seemingly innocent comments or disclosure and escalates from there.”¹¹

Some examples of warning signs include:

• Thinking of the patient when away from work.
• Sharing too much personal information with the patient.
• Providing personal contact information to the patient, for non-clinical reasons.
• Dressing differently when booked to see the patient.
• Acting or feeling possessive of the patient.
• Giving special attention or preferential treatment to the patient, different from normal practices, including scheduling more time or more sessions than required to meet therapeutic goals.
• Being defensive, embarrassed or making excuses when someone comments on, or questions your interactions with the patient.
• Giving or accepting gifts that may cause a sense of obligation or convey a special relationship.

What puts me at risk of crossing the line?

Personal and professional factors can increase your risk of engaging in questionable or inappropriate behavior.

Personal factors can include:

• Physical and mental health issues,¹² including stress or burnout.
• Social isolation at work.¹²
• Belief that the rules “don’t apply to me” or to the situation at hand.¹²
• Lack of awareness and insight regarding the culture of the population served, and failure to apply culturally aware care.

Professional factors can include:¹²

• Working in isolation (either as sole charge practitioner or due to team dysfunction resulting in isolation).
• Lack of knowledge or respect for the Standards of Practice and other professional obligations.
• Lack of clinical knowledge or experience (new to the area of practice, or failing to maintain currency of knowledge).
• Workload or other system factors.

Blurring of boundaries often occurs gradually and unintentionally; however, minor transgressions tend to lead to more significant ones if left unchecked.

Boundary violations

“Boundary violations result from a deliberate action or choice that is recognizably inappropriate and in violation of the nature of a therapeutic relationship.”¹¹

Inappropriate behaviours include:

• Sarcasm, offensive language, intimidation, teasing.
• Cultural slurs and discrimination.
• Tones of voice and body language that express impatience, condescension, or exasperation.

Prohibited behaviours include:

• Discrimination based on race, religion, ethnic origin, age, gender, sexual orientation, social, or health status.
• Verbal or physical abuse.
• Sexual relations including flirtations, suggestive jokes, and sexual innuendos.

Accepting gifts

In general, accepting gifts is part of a personal relationship, not a professional relationship. Accepting a gift from a patient always carries some degree of risk. Context is everything.

Ask yourself:

• What motivated my patient to give this gift? A desire for a “special relationship,” or future preferential treatment increases the risk of accepting a gift.
• Did my self-disclosure (i.e., my upcoming birthday) make the patient feel obligated to bring the gift?
• How will accepting the gift impact my ability to make objective, unbiased clinical decisions?
• Could the patient’s family perceive that accepting the gift constitutes fraud or theft, or be a result of manipulation?

Assessing the risk of accepting a gift

Less risk	More risk
Token value	Valuable (monetary or meangful)
For a group	To an individual
"Thank you" at discharge	During the course of treatment
Spontaneous	Solicited
Edible/Shareable	Person specific
Private pay patient	Third party insured patient

It is always up to your discretion to accept or decline a gift. If it “feels wrong” take that as a sign that you would be best to graciously decline the gift.

Consider developing strategies that discourage gift giving. An example would be developing policies that make it clear what you will do with any gift, such as donating all monetary gifts to charity, or placing consumable gifts in a staff room. This will help to minimize the pressure to give or accept gifts.

Rural practitioners

Rural practitioners often treat members of their small community with whom they have business/casual relationships or friendships and are often the only physiotherapy provider available.

These clinicians need to give some consideration on how to manage professional boundaries to ensure the person’s needs come first when they are assuming the role of a patient and that confidentiality is upheld at all times to foster trust in the broader community.

Tips:

• Develop strategies to redirect treatment-related questions to the clinic setting and social questions to the community.
• Don’t discuss patient care in non-clinical settings.

Treating family, friends + co-workers

While this may seem appealing, or in some cases be unavoidable, the overlap between a personal relationship and a professional relationship makes maintaining appropriate boundaries especially difficult.

What are the risks?

• The physiotherapist’s ability to be objective may be compromised.
• The physiotherapist may make assumptions instead of asking thorough questions.
• The patient may not want to answer questions honestly (due to embarrassment, or not wanting to hurt the physiotherapist’s feelings).
• Documentation may not adhere to regulatory standards.
• The personal relationship may suffer if the professional relationship is not successful.
• The physiotherapist may be placed in a real or perceived conflict of interest.

Be aware that the Conflict of Interest Standard of Practice requires that physiotherapists refrain from providing care to related persons and only do so if no other provider is available. In these situations, the relationship must be disclosed to third party payers or any other party that will use information about the patient’s health status to make legal, administrative (financial) or health-care decisions, the conflict of interest must be documented and formal processes must be followed.¹³  

Touch in therapeutic relationships

Q: I often give my patients hugs, especially if they are distressed. It seems like the caring thing to do. There’s nothing wrong with that, is there?
A: Offering a hug can blur the boundary between personal and professional relationships. A hug isn’t always perceived by the patient in the way the physiotherapist intended. The patient may view a hug as inappropriate, but feel obliged to accept it.¹⁴

Physiotherapy treatment regularly includes the physiotherapist entering a patient’s physical space and touching their body. Although patients may be aware of this aspect of physiotherapy before seeking care, the physiotherapist cannot assume that the patient fully understands, or consents to physical contact. Informed consent is required.  

Similarly, physiotherapists need to be aware that the consent to physical contact is context specific. Consent to physical contact in the context of providing treatment does not automatically extend to non-treatment related contact, such as hugging. Engaging in such behaviours can cause the patient to misunderstand the therapist’s intent.¹⁴

“Where physical contact is… intended for emotional support (e.g., a gentle pat on the hand or shoulder), the physiotherapist should weigh the likelihood of therapeutic benefit against potential harm or misunderstanding.”¹⁴

Professional boundaries in social media

Physiotherapists who use social media need to be aware that their online activities are subject to the same ethical and professional obligations as their usual (face-to-face) practice.

Some important considerations:

• Privacy settings are imperfect, frequently changed by online providers, and may be compromised. The physiotherapist should not assume that anything they post on social media is private or that only “friends” can see the content.
• Patients and potential patients may search social media sites for information about their health-care providers. Clearly distinguish between your personal and professional social media accounts, and ensure the content of your “professional” account remains that way.
• Even if you remove names and other identifiers from social media posts, colleagues, competitors, patients and their families may still be able to identify themselves in your comments. This may result in a breach of patient confidentiality, or damage therapeutic relationships.
• Do not initiate personal online contact with patients.
• Develop your own policy for how to deal with a patient request for online communication and how you will reply to posts that includes client information.
• Keep in mind that electronic communication lends itself to a more casual style than typically seen in professional communication. This may impact your professional reputation and your patient’s perception of your professionalism.
• Don’t post anything on social media that you wouldn’t want to appear on the news.¹⁵

For more information see Physiotherapy Alberta’s Social Media Practice Guideline.

Not sure if you’ve crossed the line?

Ask yourself these questions:

• Would I tell a colleague about this activity or behavior?
• Would another physiotherapist find my behavior acceptable?
• Would I disclose my actions to a third party payer?
• Will these actions change the patient’s expectations for care?
• Will these actions bias my clinical decision making?
• How would I feel explaining my actions to Physiotherapy Alberta’s Complaint’s Director?

A boundary has been crossed. Now what?

It is the physiotherapist’s duty to establish, maintain and monitor the boundaries of a therapeutic relationship, and to take action if a boundary has been crossed. If a boundary crossing occurs, roles need to be clarified by the physiotherapist and treatment goals re-established.

If the therapeutic relationship cannot be re-established, it is the duty of the physiotherapist to ensure that the patient is not adversely affected by any interruption in physiotherapy care.

Reflect on what led to the situation, making use of support networks, consulting with colleagues or a supervisor, or contact Physiotherapy Alberta. Document any boundary blurring or violation that occurs and the action taken to re-establish the professional boundaries of the therapeutic relationship.

Key points

1. Set the stage with appropriate boundaries from the initial assessment. Patients take their cues for acceptable behaviour based on how we speak and act.
2. Understand and be aware of potential personal vulnerabilities and professional risk factors.
3. Correct “yellow light” infractions immediately. Seemingly harmless comments from the physiotherapist or the patient can slide quickly into uncomfortable territory.
4. Take responsibility to re-establish professional boundaries, regardless of who crossed the line.
5. Document both inappropriate behaviour and measures taken to re-establish professional boundaries.
6. Maintain clear professional boundaries to protect you and your patient.

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