University of Groningen The Therapeutic Alliance in Rehabilitation Paap, Davy

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The Therapeutic Alliance in Rehabilitation

Paap, Davy

DOI:

10.33612/diss.144151915

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Publication date: 2020

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Paap, D. (2020). The Therapeutic Alliance in Rehabilitation. University of Groningen. https://doi.org/10.33612/diss.144151915

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General Discussion

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GENERAL DISCUSSION

Challenges concerning the therapeutic alliance in rehabilitation

In Chapter 1, the rationale for this thesis was outlined. Namely, improving effectiveness of rehabilitation treatments, should extend beyond conditions of specific factors and should include more common meditators of treatment effects, such as common factors (Babatunde, MacDermid, & MacIntyre, 2017). The therapeutic alliance has been judged as the most relevant common factor, on account of the supposed relationship between strength of the therapeutic alliance and outcomes of treatment (Babatunde et al., 2017; Del Re, Flückiger, Horvath, Symonds, & Wampold, 2012; Horvath, Del Re, Flückiger, & Symonds, 2011). Notwithstanding the growing evidence for the strength of this relationship, there is a need for further development and research into measuring therapeutic alliance and for conceptualization of the therapeutic alliance in rehabilitation (Babatunde et al., 2017; Hall, Ferreira, Maher, Latimer, & Ferreira, 2010). Therefore, the first overall aim of this thesis was to develop a questionnaire to measure the therapeutic alliance in rehabilitation. The second overall aim of this thesis was to provide a better understanding of the construct therapeutic alliance in rehabilitation.

Part 1: The Working Alliance Inventory for use in Rehabilitation

The Working Alliance Inventory (WAI), the most frequently used questionnaire to assess therapeutic alliance, was developed and validated for psychotherapy (Horvath & Greenberg, 1989). The WAI is also used in rehabilitation, but it was never formally validated for use in rehabilitation (Chapter 2). Therefore, the WAI might fail to account for certain aspects of the therapeutic alliance within rehabilitation. That is why the first aim of this thesis was to adapt and validate the WAI for use in rehabilitation. As a result the Working Alliance Inventory- Rehabilitation Dutch Version (ReD) was developed and validated (Chapter 3). The WAI-ReD had similar clinimetric properties as the WAI-SR (Working Alliance Inventory- Short Revised version) (Hatcher & Gillaspy, 2006). However, an important limitation of the WAI-ReD was ceiling effects ranging from 16% to 33% across the domain scores (agreement on goals, agreement on tasks and bond between the person in treatment and the healthcare professional). These ceiling effects of the (adapted) WAI were also found in other measurement studies in rehabilitation (Araujo, Oliveira, Ferreira, & Pinto, 2017; Karel et al., 2018; Takasaki, Miki, & Hall, 2019).

To address these ceiling effects we conducted a study to investigate methods for reducing ceiling effects of the WAI-ReD, by modifying the WAI-ReD response scales by changing labels (Chapter 4). The version of WAI-ReD with Visual Analogue Scales (VAS) was effective in reducing ceiling effects in domain scores (ranging between 8% and 10%, respectively) of the WAI-ReD.

Although changing the response scale in a VAS was effective in reducing ceiling effects of the WAI-ReD, in both studies (Chapters 3-4) the therapeutic alliance scores were consistently

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high. But do these high scores represent the true score of the strength of therapeutic alliance between the person in treatment and her or his healthcare professional? These high scores may also represent an overvalue of the therapeutic alliance. Moreover, ceiling effects could also indicate that items of the WAI-ReD are less relevant, lack comprehensiveness and comprehensibility (de Vet, Terwee, Mokkink, & Knol, 2011).These issues concern the content validity of the WAI-ReD.

As stated, the WAI was developed for use in psychotherapy, and it was not specifically designed for use in rehabilitation. Therefore, it can also be hypothesized that the presence of ceiling effects may be an effect of adapting the questionnaire for use in rehabilitation.

Within psychotherapy, measurement properties studies (Hatcher & Gillaspy, 2006; Hukkelberg & Ogden, 2016; Munder, Wilmers, Leonhart, Linster, & Barth, 2009; Stinckens, Ulburghs, & Claes, 2009) also reported high scores of therapeutic alliance as measured using the WAI (Chapter 2). The high WAI scores and large standard deviations in these studies suggest that ceiling effects were also present, although ceiling effects have not been explicitly mentioned in these studies, except in one (Hukkelberg & Ogden, 2016). Notwithstanding research for more than 30 years into the measurement properties of the WAI and its various adaptions for specific target-groups, no systematic review into measurement properties of the WAI has been conducted. Beside the ceiling effects issues, there was a need to investigate the other measurements properties to have better understanding of the strengths and limitations of the measurements properties of the WAI and all adapted versions and thereby to show gaps in existing measurement property research. Therefore, we conducted a systematic review for measurement properties of the WAI and all adapted versions (Chapter 5).

A finding of the systematic review (Chapter 5) was that the quality of the content validity of the WAI and all adapted versions was insufficient and therefore the level of evidence of the content validity of the WAI and all adapted versions was rated as unknown. The most frequent limitation in content validity studies was assessment of content validity without input of people in treatment and healthcare professionals regarding relevance, comprehensiveness and comprehensibility. Therefore, the level of evidence of content validity was also unknown (Chapter 5). Content validity is the most important measurement property to consider for selecting a questionnaire (Prinsen et al., 2018). When evidence of content validity is lacking, it is unknown whether the content of the WAI an adequate reflection is of the construct therapeutic alliance. Additionally, the unknown evidence of the content validity of the WAI affects the interpretation and generalizability of the findings of earlier studies (Mokkink, Prinsen, Bouter, Vet, & Terwee, 2016).

The findings of the Chapters 2-5 led us to reflective questions; we realized that in order to be able to measure therapeutic alliance in rehabilitation, we first needed to address more fundamental issues and that there was a need for a better understanding of the construct

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therapeutic alliance in rehabilitation. Therefore we decided to conduct a series of qualitative studies in three different domains of rehabilitation.

Part 2: The therapeutic alliance in rehabilitation; perspective from a

contextual view

The three qualitative studies were conducted in hand therapy, paediatric physiotherapy, and pain rehabilitation (Chapters 6-8). With these qualitative studies we wanted to explore,

bottom-up, how persons in treatment perceive, and conduct in, the context of a professional

therapeutic relationship; their perception of the aims and tasks of resp. themselves and the healthcare professionals, their perception of the role of the therapeutic bond in working on the treatment goals; and as a result their expectations of, and commitment to the treatment-process. In these three studies omnifarious persons participated in the treatment described and healthcare professionals were questioned how they perceived the therapeutic alliance.

In Chapter 6 we learned that active listening, being competent professionally and checking the reactions of the person in treatment were the most importance types of communication aspects for strengthening the therapeutic alliance, according to hand therapists. From the perspective of the hand therapists the therapeutic relationship was a vehicle for transferring knowledge and for compliance to the treatment. However, sometimes behaviours and opinions of the hand therapists were inconsistent. For instance, decision-making was the most frequently observed behaviour while it was judged by hand therapists it to be less importance for establishing a strong therapeutic alliance.

In paediatric physiotherapy, a triadic relationship (between child, parent and physiotherapist) is common, which has its own complexity regarding the therapeutic alliance (Chapter 7). Three therapeutic alliance themes were identified important for children, parents, and physiotherapists: 1) need for trust in relational skills of the physiotherapists and need for willingness of the physiotherapist to take wishes of children and parents into account during therapy, 2) importance of sharing information by all involved persons, and 3) importance of negotiation about goals and tasks of the treatment. Physiotherapists were challenged to find “the right balance” between their professional position and input, on the one hand, and the emotional needs of child and parents on the other hand. Therefore, negotiation about goals and tasks of treatment were seen as important. However, the positional inequality of the child and parents and the differences in roles and tasks appeared to be challenging in the negotiation about goals and tasks. A remarkable finding was the lack of awareness concerning the therapeutic alliance by the physiotherapists, which was expressed in unfamiliarity and lack of experience reflecting on this concept.

From the findings in Chapter 7, it appeared, similar to the findings of Chapter 6 that healthcare professionals considered technical skills important (being competent professionally) for relational trust. However, parents considered trust in the therapist’s relational skills of greater importance to the therapeutic alliance than the technical skills (Chapter 7).

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The last qualitative study was conducted in a multidisciplinary pain rehabilitation setting (Chapter 8). In a multidisciplinary pain rehabilitation setting participants have to deal with multiple treatment relationships, which in its essence leads to a different type of relationship. An important finding of this study was that participants (persons receiving rehabilitation) reported a lack of contact with their healthcare professionals about the interpretation, perception and beliefs about pain. But many avoided an open conversation with their healthcare professionals about these issues. Another finding was that part of the participants felt not comfortable being critical or evaluating the relationship with their healthcare professionals. This discomfort was expressed in the interviews by playing down their critics, changing topic, inconsistencies in their statements and or struggling with words. Most of the participants felt a loyalty conflict when they addressed negative feelings or thoughts about the treatment or treatment relationship. It was concluded that several factors obstructed the therapeutic alliance (agreement on bond), as well as the planned efficacy of the treatment-plan (agreement on goals and tasks). Therefore, it may be essential for strengthening the therapeutic alliance in multidisciplinary pain rehabilitation to focus more on personalized collaboration, agreement on the rationale concerning pain, agreement on diagnoses and treatment plans from the start of treatment. During treatment the healthcare professionals should systematically take into account the perceptions and needs of the participants, and at the same time be aware of the difficulties for many persons in expressing their feelings or needs.

Implications

Interpretation problems and ceiling effects of the WAI (including the WAI-ReD)

Based on the findings in this thesis it can be questioned whether the WAI is suitable for use in multidisciplinary pain rehabilitation program or suitable for use in other domains of rehabilitation, because without participants’ context it is difficult to interpret the WAI results as illustrated in the next two examples: (1) The first participant fills in a high score of the WAI and this participant experiences a dependent relationship with her healthcare professional. She does not feel comfortable expressing negative feelings or being critically to her healthcare professional; (2) A more autonomic participant feels comfortable being critically and was more demanding in the collaboration, and scores lower than the previous one. However, this participant may experience a stronger collaboration with her healthcare professional. Hence, it can be questioned if the high score of the WAI does truly reflect a strong working relationship.

Another limitation in interpretation of the WAI scores is that persons in treatment may associate the questions of the WAI rather with how they feel treated (referring to “kindness” and “attention”) than with collaboration (Chapter 8). The scores in Chapter 8 seem superficial when taking into account how participants considered the therapeutic alliance with their healthcare professionals. Moreover, a complicating factor when interpreting WAI scores is that the concept therapeutic alliance was not in the centre of concern of the participants in treatment nor of the healthcare professionals (Chapters 6-8). Both, were not used to reflect

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on this concept. Along with the discomfort of being critical or evaluating the relationship with their healthcare professionals may explain the ceiling effects of the WAI.

Previously it has been postulated that the WAI lack of items that asses disagreement (related to goals and tasks) or tensions and ruptures in the therapeutic relationship (Doran, Safran, Waizmann, Bolger, & Muran, 2012). But in psychotherapy disagreement or tension and ruptures do occur regularly (Safran, Muran, & Eubanks-Carter, 2011) and both persons in treatment and healthcare professionals underreported these issues due lack of awareness or feelings of discomfort about them (Miller-Bottome, Talia, Safran, & Muran, 2018). Taking the implications of Chapters 6-8 also into account, it can be concluded that high scores (ceiling effects) of the WAI do not necessary represent a strong therapeutic alliance.

WAI-ReD for use in Rehabilitation

Before the WAI-ReD can be used in rehabilitation for measuring therapeutic alliance, more research is needed. In Chapter 3 a Flemish version of the WAI-SR was adapted for use in rehabilitation and this resulted in the WAI-ReD, therefore this version may be more suitable for measuring therapeutic alliance in rehabilitation. However, three aspects may limit usefulness of the WAI-ReD in rehabilitation: 1) The overall quality of evidence for development and content validity of the ReD is unknown (Chapter 5); 2) Ceiling effects or high scores of the WAI-ReD and the lack of items that assess tensions and ruptures in the therapeutic relationship (Chapters 4-5 and 8); and 3) The evidence related to the measurement properties of the WAI(-ReD) of the WAI and its adapted versions is inconclusive (Chapter 5).

Challenges of measuring the therapeutic alliance in rehabilitation

In the past three decades of measurement property research of the WAI and all adapted versions, most measurements studies provided evidence for construct validity, based on correlations with another therapeutic alliance measure, or correlations with a therapeutic outcome (Chapter 5). This type of evidence has its limitations, because the theory of therapeutic alliance was developed to explain the mechanism of a working relationship in psychotherapy, how it functions and what it does but not how it should be measured (Bordin, 1979; Flückiger, Del Re, Wampold, & Horvath, 2018). The theory is lacking falsifiable hypotheses. Therefore, the theory of therapeutic alliance needs further development, because without strong theories and specific and challenging hypotheses, it is not possible to provided stronger evidence for construct validity (de Vet et al., 2011).

Another important issue concerning measuring therapeutic alliance is that there is a need for a theory clarifying related constructs (Flückiger et al., 2018). A theory explaining for instance how therapeutic alliance, empathy, feedback from person in treatment, warmth, trust can be distinguished and to what extent these constructs are related to each other, how they can be distinguished, and how the relatedness can be quantified. Currently, there are over 70 different measures to assess therapeutic alliance or related constructs, and new measures are continuously developed (Doran, 2016). Maybe there is no need for developing new

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measurement instruments, but more a need for studies that provided a further development of the theory of the therapeutic alliance in order to measure therapeutic alliance adequately. However, validation of a measurement instrument is a iterative process, which results from validation studies that can be used for further development of the theory (de Vet et al., 2011; Prinsen & Terwee, 2019).

The two issues described above affect measuring therapeutic alliance in rehabilitation, but there are more issues to address which needs clarification. For instance, what type of therapeutic alliance is needed in rehabilitation, and does this type of therapeutic alliance affect the method of measurement? Are different types of therapeutic alliance needed across the different domains of rehabilitation? Hence there is need for further conceptualization of the therapeutic alliance within rehabilitation.

A promising idea coming from the field of psychotherapy is to assess the therapeutic alliance when there is a problem (a strain or rupture) and when this problem is repaired (Muran, 2019). Such an assessment could be observer-based using the Rupture Resolution Rating System (3RS) (Eubanks, Muran, & Safran, 2015). Results from a meta-analysis showed a moderate inverse association between strength of these strains and ruptures without repair and therapeutic outcome (Eubanks, Muran, & Safran, 2018). Measurement property studies provide some evidence for validity, reliability and feasibility of the 3RS for measuring the process of the treatment (and strains or ruptures) and it is able to predicting dropout from treatment. However, more research is needed with this measurement instrument before it can be used in rehabilitation (Eubanks, Lubitz, Muran, & Safran, 2019).

The therapeutic alliance in rehabilitation

The findings of the qualitative studies described in Chapters 6-8, in three different domains of rehabilitation may have important implications for the conceptualization of the therapeutic alliance in rehabilitation.

First, the lack of awareness and experience in reflecting about the therapeutic alliance by healthcare professionals on the one hand (Chapters 6- 7), and lack of negotiation between the persons in treatment and their healthcare professionals on the other hand (Chapters 7-8). In addition, persons in treatment reported that they regularly avoid open communication with their healthcare professionals about relational issues. The findings of Chapters 7-8 show a contrast between the satisfaction concerning the therapeutic relationship emphasized by the persons in treatment, and the dilemmas and tensions in the therapeutic relationship reported in the interviews. This contrast suggests that persons in treatment in rehabilitation regularly have disagreement regarding treatment-aims and other treatment issues as well as regularly avoid expressing negative feelings and thoughts. This disagreement and avoidance indicates the existence of strains and ruptures in the therapeutic alliance in rehabilitation. To improve the therapeutic alliance, it would help if healthcare professionals became more sensitive to the existence and influence of (subtle indications of) strains and ruptures in the

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therapeutic relationship (Chapter 7). Repairing these strains and ruptures may contribute to the empowerment and relational equality of the person in treatment which may result in a stronger therapeutic alliance and more person-centred care (Safran & Kraus, 2014). Moreover, person-centred care underpins a collaborative therapeutic alliance between the person in treatment and the healthcare professional (Wade, 2015), which can improve therapeutic outcome (Weiner et al., 2013).

Second implication, from the persons’ in treatment perspective (Chapter 8) the person in treatment and their healthcare professionals differ in paradigm (biomedical or biopsychosocial) regarding pain and they are often not aware of this difference or lack the capacity to communicate about this difference. Although the pain rehabilitation program aims to work according to a biopsychosocial paradigm, the persons in treatment had difficulties to comprehend, accept, and to recognize this paradigm. These difficulties resulted in disagreements regarding the goals and tasks, and therefore also affected negatively the therapeutic alliance. Although, this finding involved people in pain rehabilitation, it is likely that these findings are transferable to other domains in rehabilitation.

Rehabilitation has traditionally a biomedical focus (Wade & Halligan, 2017). However, most guidelines recommend to implement interventions including physical, psychological, social and lifestyle factors (Engel, 1977; Gatchel, Peng, Peters, Fuchs, & Turk, 2007; Lin et al., 2020). Biopsychosocial approaches often involve a change in healthcare professionals attitudes and beliefs (Holopainen et al., 2020), moreover, it underpins and leads to person-centred care. In addition, a biopsychosocial approach requires a different type of therapeutic relationship in comparisons with a biomedical approach. Its requires a more negotiated, collaborative relationship and its requires that the person in treatment and healthcare professionals share their common understanding of the illness. When the person in treatment and healthcare professionals disagree, treatment may fail (Horowitz, Rein, & Leventhal, 2004). Findings of a systematic review and meta-synthesis of qualitative studies show that healthcare professionals struggle to deal with psychosocial or biomedical issues and have concerns about professional boundaries (Holopainen et al., 2020). Additionally, despite of 40 years after introduction of the biopsychosocial model, most healthcare professionals and managers are still unaware of it (Lane, 2014). A first improvement could be an awareness of the patient being a person and improving therapeutic alliance with this person and sharing of care and resources (Wade & Halligan, 2017). These improvements could result in a more holistic approach which has the potential to contribute to a more favourable and sustainable rehabilitation.

Last, the above mentioned implications of the findings of this thesis concerning therapeutic alliance in rehabilitation suggest there is a need for incorporating relational-therapeutic skills and knowledge including the theory of the therapeutic alliance as a professional competence in the study curriculum of the healthcare professionals in rehabilitation. Perhaps by introducing therapeutic alliance in education it will support a full implementation of the biopsychosocial approach in treatment within rehabilitation.

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However, despite the growing evidence of relationship with therapeutic alliance and therapeutic outcomes in rehabilitation (Babatunde et al., 2017; Hall et al., 2010), the existing studies fail to provide strong evidence and causality of this relationship (Taccolini Manzoni, Bastos de Oliveira, Nunes Cabral, & Aquaroni Ricci, 2018). Therefore there is a need for future studies to provide more evidence and understanding of the relationship between therapeutic alliance and therapeutic outcome in rehabilitation.

Limitations and strengths

As part of the thesis we wanted to conduct a study to investigate the effect of a therapeutic alliance training of rehabilitation professionals on therapeutic outcomes. However, no valid measurement had been developed for measuring therapeutic alliance in rehabilitation (Chapter 2). Therefore, we started with adapting and re-contextualising of an existing “valid” measurement instrument developed in psychotherapy where the construct therapeutic alliance had originated (Chapter 3). Beside the ceiling effects of the WAI-ReD previous described, several limitations had to be taken into account. Generally within rehabilitation multiple healthcare professionals are involved in the treatment of an individual. Persons in treatment have to deal with multiple treatment relationships. Both, the original WAI or the WAI-ReD aims to measure the therapeutic alliance in a one to one relationship, between the person in treatment and the healthcare professional. Another limitation was the use of the Flemish version of the WAI-SR as a starting point. An English to Dutch forward backward translation procedure might have been more accurate. However, Flemish is closer to Dutch than English and therefore translation seemed more straightforward.

The version of WAI-ReD with Visual Analogue Scales (VAS) was effective in reducing ceiling effects (Chapter 4). However, in the ceiling effect study participants were recruited from Department of Rehabilitation Medicine of the University Medical Center Groningen (UMCG) and physiotherapy practices in the area of Groningen. The total scores of the WAI-ReD were lower in participants recruited in the physiotherapy practices compared to those recruited by physiotherapists in the UMCG suggesting selection bias. Another explanation could be that the number of treatments is different between these locations as well as severity, or duration of complaints.

The results of Chapter 5 show that evidence on the measurements properties of the WAI is largely missing. Other important result of this systematic review was ceiling effects were probably also present in most measurement property studies of the WAI. These ceiling effects limit accurate interpretation of data and reduces responsiveness of the measurement instrument (de Vet et al., 2011; Streiner, Norman, & Cairney, 2015). A strength of the systematic review was the use of the COSMIN standards, since these standards use an up-to-date methodology (Prinsen et al., 2018; Terwee et al., 2018). However, these standards make it difficult to distinguish between poor reporting versus poor methodological quality (Craxford, Deacon, Myint, & Ollivere, 2019). This limitation of the COSMIN standards reduces its validity for methodological assessment.

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A strength of this thesis was that we decided based on Part 1, to conduct qualitative studies in Part 2 to provide more understanding of the construct therapeutic alliance in rehabilitation. In these three qualitative studies with different methodological approaches (Chapters 6-8) omnifarious persons participated in treatment and healthcare professionals were questioned how they perceived the therapeutic alliance which resulted in different perspectives of the therapeutic alliance in rehabilitation. However, the heterogeneity of these qualitive studies makes it difficult to compare the results.

Chapter 6 was a first exploration and qualitative study in this thesis to investigate the therapeutic alliance in hand therapy. This chapter build the fundament for the two other qualitative studies in Chapters 7-8. However, this study has several limitations for instance, there was a single observer of live treatment sessions, using a non-standardized outcome measure. This limited the accuracy and validity of the data collected. Another limitation of the study was that data saturation was not reached, although the five interviews provided understanding of the factors hand therapist found to be important to strengthen the therapeutic alliance.

In Chapter 7, the exploration of perceptions and preferences of children, parents, and physiotherapists regarding the therapeutic alliance in paediatric physiotherapy in a rehabilitation setting resulted in three themes. This qualitive study included children who had a wide variety of chronic diagnoses. Children with more sever diseases may have more complex and specific needs which limits the transferability of the findings. Another limitation was that interviews (child, parent and physiotherapist) were not repeated after some time. For further conceptualization of therapeutic alliance in rehabilitation it is interesting how participants experienced the therapeutic alliance differently during and after completing the treatment and it could be fruitful to explore how the therapeutic alliance may change over time.

The results of Chapter 8 show that many factors within a multidisciplinary pain rehabilitation program obstructed the development of a therapeutic alliance (strength of the bond), as well as of the planned efficacy of the treatment-plan (agreement on goals and tasks). In this qualitive study 26 participants with chronic pain participating in a pain rehabilitation program were interviewed. No interviews were conducted with the healthcare professionals; it is interesting to analyse participants and healthcare professionals in dyads. The comparison of dyads may provide better insight between the interaction between participants of pain rehabilitation and healthcare professionals.

Conclusions

Currently, there is a lack of awareness of and experience in reflecting on the therapeutic alliance by the healthcare professionals and rehabilitation participants. The WAI-ReD can be used to measure therapeutic alliance in an one-to-one relationship in rehabilitation, but outcomes should be interpreted carefully since content validity is unclear. Additionally, the

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type of therapeutic alliance needed in rehabilitation for optimal treatment results, is unclear and should be explored as well as ways to measure that type of alliance.

A strong therapeutic alliance has the potential to contribute to a more favourable and sustainable rehabilitation. The findings of the qualitative studies suggest that for improving the therapeutic alliance in rehabilitation, it would help if healthcare professionals became more sensitive to the existence and influence of (subtle indications of) strains and ruptures in the therapeutic relationship. Repairing these strains and ruptures may contribute to the empowerment and relational equality of the person in treatment which may result in a stronger therapeutic alliance and more person-centred care in rehabilitation.

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REFERENCES

Araujo, A. C., Oliveira, C. B., Ferreira, P. H., & Pinto, R. Z. (2017). Measurement properties of the Brazilian version of the Working Alliance Inventory (patient and therapist short-forms) and Session Rating Scale for low back pain. Journal of Back and Musculoskeletal Rehabilitation, 30(4), 879–887. https://doi.org/10.3233/ BMR-160563.

Babatunde, F., MacDermid, J., & MacIntyre, N. (2017). Characteristics of therapeutic alliance in musculoskeletal physiotherapy and occupational therapy practice: a scoping review of the literature. BMC Health

Services Research, 17(1), 375. https://doi.org/10.1186/s12913-017-2311-3.

Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy:

Theory, Research & Practice, 16(3), 252–260. https://doi.org/10.1037/h0085885

Craxford, S., Deacon, C., Myint, Y., & Ollivere, B. (2019). Assessing outcome measures used after rib fracture: A COSMIN systematic review. Injury, 50(11), 1816–1825. https://doi.org/10.1016/j.injury.2019.07.002. de Vet, H. C. W., Terwee, C. B., Mokkink, L. B., & Knol, D. L. (2011). Measurement in medicine: a practical guide.

New York: Cambridge University Press.

Del Re, A. C., Flückiger, C., Horvath, A. O., Symonds, D., & Wampold, B. E. (2012). Therapist effects in the therapeutic alliance‐outcome relationship: A restricted-maximum likelihood meta-analysis. Clinical

Psychology Review, 32(7), 642–649. https://doi.org/10.1016/j.cpr.2012.07.002.

Doran, J. M. (2016). The working alliance: Where have we been, where are we going? Psychotherapy Research,

26(2), 146–163. https://doi.org/10.1080/10503307.2014.954153.

Doran, J. M., Safran, J. D., Waizmann, V., Bolger, K., & Muran, J. C. (2012). The Alliance Negotiation Scale: Psychometric construction and preliminary reliability and validity analysis. Psychotherapy Research,

22(6), 710–719. https://doi.org/10.1080/10503307.2012.709326.

Engel, G. (1977). The need for a new medical model: a challenge for biomedicine. Science, 196(4286), 129–136. https://doi.org/10.1126/science.847460.

Eubanks, C. F., Lubitz, J., Muran, J. C., & Safran, J. D. (2019). Rupture Resolution Rating System (3RS): Development and validation. Psychotherapy Research, 29(3), 306–319. https://doi.org/10.1080/10 503307.2018.1552034.Eubanks, C. F., Muran, J. C., & Safran, J. D. (2015). Rupture resolution rating system (3RS): Manual. Unpublished Manuscript, Mount Sinai-Beth Israel Medical Center, New York. Eubanks, C. F., Muran, J. C., & Safran, J. D. (2018). Alliance rupture repair: A meta-analysis. Psychotherapy,

55(4), 508–519. https://doi.org/10.1037/pst0000185.

Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy, 55(4), 316–340. https://doi.org/10.1037/pst0000172. Gatchel, R. J., Peng, Y. B., Peters, M. L., Fuchs, P. N., & Turk, D. C. (2007). The biopsychosocial approach to

chronic pain: Scientific advances and future directions. Psychological Bulletin, 133(4), 581–624. https:// doi.org/10.1037/0033-2909.133.4.581.

Hall, A. M., Ferreira, P. H., Maher, C. G., Latimer, J., & Ferreira, M. L. (2010). The Influence of the Therapist-Patient Relationship on Treatment Outcome in Physical Rehabilitation: A Systematic Review. Physical Therapy,

90(8), 1099–1110. https://doi.org/10.2522/ptj.20090245.

Hatcher, R. L., & Gillaspy, J. A. (2006). Development and validation of a revised short version of the working alliance inventory. Psychotherapy Research, 16(1), 12–25. https://doi.org/10.1080/10503300500352500. Holopainen, R., Simpson, P., Piirainen, A., Karppinen, J., Schütze, R., Smith, A., … Kent, P. (2020).

Physiotherapistsʼ perceptions of learning and implementing a biopsychosocial intervention to treat musculoskeletal pain conditions. PAIN, 0(0), 1–19. https://doi.org/10.1097/j.pain.0000000000001809. Horowitz, C. R., Rein, S. B., & Leventhal, H. (2004). A story of maladies, misconceptions and mishaps: effective management of heart failure. Social Science & Medicine, 58(3), 631–643. https://doi.org/10.1016/ S0277-9536(03)00232-6.

Horvath, A. O., Del Re, A. C., Flückiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy.

Psychotherapy, 48(1), 9–16. https://doi.org/10.1037/a0022186.

Horvath, A. O., & Greenberg, L. S. (1989). Development and validation of the Working Alliance Inventory. Journal

of Counseling Psychology, 36(2), 223–233. https://doi.org/10.1037/0022-0167.36.2.223.

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Hukkelberg, S., & Ogden, T. (2016). The short Working Alliance Inventory in parent training: Factor structure and longitudinal invariance. Psychotherapy Research, 26(6), 719–726. https://doi.org/10.1080/10503 307.2015.1119328.

Karel, Y., Thoomes-de Graaf, M., Scholten-Peeters, G., Ferreira, P., Rizopoulos, D., Koes, B. W., & Verhagen, A. P. (2018). Validity of the Flemish working alliance inventory in a Dutch physiotherapy setting in patients with shoulder pain. Physiotherapy Theory and Practice, 34(5), 384–392. https://doi.org/10.1080/09 593985.2017.1400141.

Lane, R. D. (2014). Is it possible to bridge the Biopsychosocial and Biomedical models? BioPsychoSocial

Medicine, 8(1), 3. https://doi.org/10.1186/1751-0759-8-3.

Lin, I., Wiles, L., Waller, R., Goucke, R., Nagree, Y., Gibberd, M., … O’Sullivan, P. P. B. (2020). What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. British Journal of Sports Medicine, 54(2), 79–86. https:// doi.org/10.1136/bjsports-2018-099878.

Miller-Bottome, M., Talia, A., Safran, J. D., & Muran, J. C. (2018). Resolving alliance ruptures from an attachment-informed perspective. Psychoanalytic Psychology, 35(2), 175–183. https://doi.org/10.1037/pap0000152. Mokkink, L. B., Prinsen, C. A. C., Bouter, L. M., Vet, H. C. W. de, & Terwee, C. B. (2016). The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) and how to select an outcome measurement instrument. Brazilian Journal of Physical Therapy, 20(2), 105–113. https://doi. org/10.1590/bjpt-rbf.2014.0143.

Munder, T., Wilmers, F., Leonhart, R., Linster, H. W., & Barth, J. (2009). Working Alliance Inventory-Short Revised (WAI-SR): psychometric properties in outpatients and inpatients. Clinical Psychology & Psychotherapy,

17(3), 231–239. https://doi.org/10.1002/cpp.658.

Muran, J. C. (2019). Confessions of a New York rupture researcher: An insider’s guide and critique.

Psychotherapy Research, 29(1), 1–14. https://doi.org/10.1080/10503307.2017.1413261.

Prinsen, C. A. C., Mokkink, L. B., Bouter, L. M., Alonso, J., Patrick, D. L., De Vet, H. C. W., & Terwee, C. B. (2018). COSMIN guideline for systematic reviews of patient-reported outcome measures. Quality of Life

Research, 27(5), 1147–1157. https://doi.org/https://doi.org/10.1007/s11136-018-1798-3.

Prinsen, C. A. C., & Terwee, C. B. (2019). Measuring positive health: for now, a bridge too far. Public Health,

170, 70–77. https://doi.org/10.1016/j.puhe.2019.02.024.

Safran, J. D., & Kraus, J. (2014). Alliance ruptures, impasses, and enactments: A relational perspective.

Psychotherapy, 51(3), 381–387. https://doi.org/10.1037/a0036815.

Safran, J. D., Muran, J. C., & Eubanks-Carter, C. (2011). Repairing alliance ruptures. Psychotherapy, 48(1), 80–87. https://doi.org/10.1037/a0022140.

Stinckens, N., Ulburghs, A., & Claes, L. (2009). De werkalliantie als sleutelelement in het therapiegebeuren.

Meting Met Behulp van de WAV-12: De Nederlandse Vertaling van de Working Alliance Inventory. Tijdschrift Klinische Psychologie, 39, 44–60.

Streiner, D. L., Norman, G. R., & Cairney, J. (2015). Health measurement scales: a practical guide to their

development and use. New York: Oxford University Press, USA.

Taccolini Manzoni, A. C., Bastos de Oliveira, N. T., Nunes Cabral, C. M., & Aquaroni Ricci, N. (2018). The role of the therapeutic alliance on pain relief in musculoskeletal rehabilitation: A systematic review.

Physiotherapy Theory and Practice, 34(12), 901–915. https://doi.org/10.1080/09593985.2018.1431343.

Takasaki, H., Miki, T., & Hall, T. (2019). Development of the Working Alliance Inventory-Short Form Japanese version through factor analysis and test–retest reliability. Physiotherapy Theory and Practice, 36(3), 444–449. https://doi.org/10.1080/09593985.2018.1487492.

Terwee, C. B., Prinsen, C. A. C., Chiarotto, A., Westerman, M. J., Patrick, D. L., Alonso, J., … Mokkink, L. B. (2018). COSMIN methodology for evaluating the content validity of patient-reported outcome measures: a Delphi study. Quality of Life Research, 27(5), 1159–1170. https://doi.org/10.1007/s11136-018-1829-0. Wade, D. (2015). An interdisciplinary approach to neurological rehabilitation. Oxford textbook of

neurorehabilitation (pp. 8–17). New York: Oxford University Press.

Wade, D., & Halligan, P. W. (2017). The biopsychosocial model of illness: a model whose time has come.

Clinical Rehabilitation, 31(8), 995–1004. https://doi.org/https://doi.org/10.1177/0269215517709890.

(15)

228

Weiner, S. J., Schwartz, A., Sharma, G., Binns-Calvey, A., Ashley, N., Kelly, B., … Harris, I. (2013). Patient-Centered Decision Making and Health Care Outcomes. Annals of Internal Medicine, 158(8), 573. https://doi. org/10.7326/0003-4819-158-8-201304160-00001.

(16)

(17)