Four foundational conditions fostering engagement between physiotherapist (PT) and patient within a therapeutic relationship were identified and labeled: (a) Present, (b) Receptive, (b) Genuine, and (d) Committed.
Present
Being present reflects physiotherapists’ and patients’ intentions and abilities to be in-the-moment or embodied in time and space. Physiotherapists make conscious choices about the amount of time they spend in direct proximity with patients in a potentially chaotic setting laden with competing responsibilities. Therapists described instances when remaining with the patient was believed to be of utmost importance, such as when a patient needed “more one-on-one time” (PT-J) for guidance with exercises or when experiencing emotional distress:
PT-B:... they start crying. .. the biggest thing. .. is don’t pull away. Don’t walk out of the room. Don’t leave them.
While scheduling longer sessions (e.g., 30 min) was an option, physiotherapists also described many impromptu situations where a decision was made to remain with a patient, despite the allotted timeframe:
PT-I: I think that if I’m with somebody who’s gone through 20 years of struggle with this, I think I have to take more time at the beginning.
Patients noticed their therapists’ efforts to “spend more time with me than they should” (Patient-B). Patient-E appreciated that “time was of no consequence” because it gave the impression that the therapist was willing to do “whatever it takes” to address the issue. Patients also noticed when therapists were not present and the negative impact this had on their experiences, such as when they perceived therapists were rushing. Moreover, patients were able to distinguish between a ‘busy’ therapist and a ‘rushed’ therapist, where a busy therapist could be present despite the hectic environment:
Patient-D: They were busy as can be, just on a cycle going from one to the next to the next and coming back. They always took the time to make you feel like you were a decent person.
In addition, physiotherapists and patients described the importance of creating a “bubble” (PT-K) that allows full engagement. Although therapists could be distracted by multiple responsibilities, a busy caseload, and personal factors (e.g., family stressors), they took personal responsibility to “turn those issues off” (PT-G) when with patients. Therapists also described using non-verbal cues and manipulating material space, such as adjusting seating arrangements and using private rooms versus curtained cubicles to help patient and therapist “narrow down” (PT-E). Patients also spoke of their need to be present during the interaction. Notably, they spoke of being in-the-moment to understand their bodies and “feel the treatment” (Patient-E) because “if I can’t tell her [PT] how it’s feeling or how it’s reacting, I can’t help her” (Patient-A).
Receptive
To be receptive, physiotherapists and patients must enter interactions with: a) an open attitude to negotiate appropriate treatment plans; and b) a focused receptivity to identify salient issues and needs.
Open attitude
Having an open attitude requires physiotherapists and patients to manage personal agendas and be willing to be “open to all these things [treatments]” (Patient-A). Even though therapists have specific knowledge and skills that inform treatment plans, they also need “... to be open and listening and not go into this [interaction] with a pre-determined agenda”(PT-B). This includes a willingness to listen to the patient’s story because it is “... important to me as the patient that you hear and understand what I need you to help me [with]” (Patient-E). Allowing patients to tell their stories can be important for developing a safe and receptive atmosphere:
PT-I: The big thing is that patients that are struggling and... really have big problems, they need to tell their story. You need to listen and shut your mouth.
The same is true for patients. Just as therapists need to “... listen to all their [patients’] fears, all their issues...” (PT-G), to create a working relationship, patients also need to listen and be open to physiotherapists’ suggestions:
PT-G: You try to explain what you are doing and they keep interrupting you. They keep challenging everything you say... They don’t listen to anything you say. That I find really difficult.
Focused receptivity
In addition to an open attitude, physiotherapists must also be attentive to the situation at hand. This is achieved by actively considering patients’ verbal and non-verbal cues. For example, focused receptivity helps therapists gain insight into patients’ physical and psychological states:
PT-B: They are guarded, they are tightening. .. you can just see that they are upset.
PT-A: If they are not talking to you. .. or if their tone has raised or heightened then you know something is going on...
In addition to focusing on behaviours, therapists also spoke of how being receptive to patients’ comments, often noted either mentally or in the chart, was essential for identifying how to connect with patients about their lives. This enabled them to “... gauge where that person’s at and what their interests are...” (PT-E). This receptivity fosters deeper engagement during the immediate interaction and provides opportunity for the same in the future.
Genuine
To be genuine is to be real or convey sincerity in the present. Being genuine in a therapeutic relationship has three aspects: a) being yourself; b) being honest; and c) investing in the personal.
Being yourself
To convey genuineness, individuals must remain congruent with their personal qualities and values, while maintaining an accepting attitude. To do this, physiotherapists and patients must feel comfortable enough to sincerely present themselves, not putting on a facade:
PT-I: I’m pretty open with people. I can talk to anybody... I don’t change who I am in any role in my life. .. I am who I am. I think patients probably feel comfortable asking me that because that’s kind of how we interact as people.
Patients notice when physiotherapists are being themselves or have “warm”, “personable”, or “approachable” personalities. In doing so, therapists create an environment where patients can also express themselves. Therapists curb judgment of patients and are open to “where that individual is” (PT-E) by acknowledging their unique personalities, life stories, and social and cultural realities. In addition, freedom for patients to be themselves extends to their bodies and injuries. Physiotherapists can mitigate patients’ feelings of vulnerability that give rise to negative perceptions of their bodies and injuries:
Patient-D:... [he] was very good at making me feel like you weren’t abnormal... I don’t want to be singled out as out of shape or old or... I didn’t quite know what to expect when the physiotherapist came in... I expected a fair bit of judgmenty-type things the way that doctors would sometimes.
Being honest
While honesty is likely a necessary condition for any healthy relationship, there are two main qualities that describe being honest in the physiotherapy context: transparency and directness. Being transparent involves therapists and patients providing the necessary information to help the patient progress in a safe and meaningful way. This can include impressions of the physical problem and rehabilitation process; personal limitations in skill and knowledge; patient participation and outcome expectations; and the therapist’s role and responsibilities:
PT-B:... being realistic about what’s going to happen. .. I’m really honest with people about that and I explain to them and especially with those more complex, that they are 80% of what’s going to make a difference.
Patients must also be transparent about information related to their conditions, or as Patient-C claims, it “... is important for the patient to tell the whole truth...” Physiotherapists agreed they needed to trust that “... they [patients] are telling you the truth... all the factors that are contributing.” (PT-E).
In addition to being transparent, the physiotherapist must also be direct in the tone and manner of communication. Specifically, therapists must be clear and forthright. Although being direct might be interpreted as stern, especially in challenging situations, the tone can also convey concern or compassion. Ultimately, the therapist’s intention is to be clear, leaving little doubt about the message:
PT-H: She did have an injury but I had to explain to her that, “The injury that you have cannot cause all of the problems that you are having. Let’s try to figure out what else is causing it.”
Investing in the personal
A primary focus of physiotherapy is to restore or maintain physical mobility and function. However, many patients and physiotherapists revealed that a personal aspect was important to the overall quality of the therapeutic relationship. Being invested in the personal was revealed through an interest in the person and a willingness to disclose about self.
Taking an interest in the person pertains to therapists’ or patients’ desires to broaden the scope of caring to an interest in the other’s life beyond the reason for referral:
PT-C:... folks that ask me how I’m doing, folks that ask me how things are going, we end up talking about things unrelated to their condition or the weather... We have an interest in each other.
Even though therapists often need to know about patients’ lives for therapeutic reasons, those invested in the personal are willing to get to know the patient as a person, demonstrating an authentic interest in people’s lives. This investment can put the patient at ease:
PT-I: Even when my questioning starts, you know I always ask them about them first. So, I always make it clear that that’s really important to me... I ask them to tell me a little bit about yourself outside of what’s brought you here... What sorts of things do you enjoy doing? Even the way I ask those questions is very different. ... I can get to a person’s level of comfort and they can relax a little bit if I ask them questions that are not directed to their sore knee or sore shoulder. . .
Even though roles and professional boundaries might make it difficult for patients to express an interest in their physiotherapists’ lives, they could be “genuinely interested” in getting to know their therapists, asking “... almost as many questions as you ask them” (PT-J). Furthermore, some patients found value in knowing their physiotherapists on a human level:
Patient-B: It makes a huge difference knowing that they can relate to you, first of all and they have a real life. They are not just a physio... these people go home and have kids and have a family. It’s nice. You are both real people so you should probably treat each other like people.
Another aspect of investing in the personal is demonstrating a willingness to disclose. Being willing to disclose means offering something more personal and not necessarily related to the primary intent of the interaction. Therefore, disclosures can be social or therapeutic. Most therapists recalled they had different perceptions of what constituted an appropriate disclosure:
PT-F: ... you can talk about personal interests and not get personal so hobbies and what you might do in your non-professional life that doesn’t have to do with anything intimate... sports are good, music is good, leisure activities. . .
Patients’ investments in the personal also included disclosing more personal aspects of their physical and emotional challenges, including issues pertaining to sexuality or mood. Although one therapist commented that there are some patients who “... are comfortable disclosing that information to you” (PT-A), this same therapist also claimed that patient disclosures sometimes required a “leap of faith” in the therapist. Patients agreed, commenting that disclosure of their physical issues and personal lives was easier as “... you get more comfortable so you’re more willing to tell them what you are feeling” (Patient-C).
There is a spectrum of how much physiotherapists and patients are willing to invest in the personal (see Fig. 1). For example, PT-D was very clear he was not interested in his patients’ personal lives, making “... a point to stay outside of those kinds of conversations”, nor was he interested in discussing anything outside of the clinical problem:
PT-D: I really don’t talk much on the personal side. I really don’t think any of my patients even know how many kids I have or what I do in my spare time. I don’t think any one of them knows that... that’s purely on the personal side.
Therefore, it appears there are different ways to be in a therapeutic relationship:
PT-K: My partner is exactly the opposite of me. .. my professional boundaries and his professional boundaries are on either side of the continuum of professional boundaries.
Committed
To be engaged, physiotherapists and patients must be committed to their roles within the therapeutic relationship. A patient’s well-being matters, or, as PT-A claimed, “their well-being is your well-being...” This speaks to an ethic of care that encompasses physiotherapists’ professional duty and the desire to be of service to others to restore patients’ well-being. Some physiotherapists and patients stated that therapists do not “fix” patients, but that both have roles they must commit to:
Patient-B: You have to take care of yourself in order for them [physiotherapists] to be able to take care of you too. If you are just going to go and expect them to do it all for you, it’s not going to happen. You’re not going to get better, I find.
These points considered, there are two aspects that characterize being committed: (a) committed to understanding and (b) committed to action.
Committed to understanding
Both physiotherapists and patients must be motivated to understand the patient’s situation. When the physiotherapist is committed to understanding the patient, there is a “... need to understand more about what you [patient] are describing...”(PT-B). Therapists were not satisfied with a generic overview of the patient’s situation:
PT-D:. .. if you give out the impression that you know what’s happening in this person’s back without showing them the interest or without making an effort in understanding it, you won’t be able to help them.
The physiotherapist is not only dedicated to understanding the patient’s physical situation, but also “a picture of the unspoken” (PT-C) or the psychosocial factors that could be influential:
PT-H: If a person has what we would call a chip on their shoulder let’s say, you try to find out what the chip is. I see it as part of my job to get over that chip... If I can find out what brought it on... Empathize. Sort of understand.
Even though the physiotherapist is expected to try to understand, it was also clear that patients needed to invest in understanding their situations:
Patient-E: I felt I needed to understand as much of my own physiology and biology in order to help what it is that she was trying to do for me, so I could help myself.
Committed to action
Being committed to action involves making “all efforts” (PT-D) to honour the best interests of the patient. Physiotherapists “... do their best to do the best that they can...” (Patient-C), and will go beyond due diligence to help patients achieve goals. Therapists committed to action recognize there are many facets of care to be considered, and that they may need to “go that extra little mile” (PT-A) in complicated situations.
Patients must also be committed to act in their own best interests. Physiotherapists spoke about the necessity of patient “buy in” or as PT-G stated, “... they also have to agree with what you are saying and be motivated to take part in the treatment themselves because it's not just passive.” Patients seemed to understand that their motivation to participate was essential:
Patient-G:... they [patients] are expecting the physiotherapist to “fix them” and they don’t need to fix themselves... I understand what physio means and how I need to aid myself as well.
Patients highlighted that continuity, described as the patient seeing the same therapist versus being shuttled between therapists, is an important part of being committed. Having “your therapist” (Patient-B) facilitates progression of the session, reduces the need for the patient to familiarize a new therapist, and allows the physiotherapist to get to know the patient’s body, activity levels, and treatment history:
Patient-G: “What’s your past injuries? How many injuries have you had? What's your sport history?” All that stuff. When I saw (name of physiotherapist), it was like, “Oh hey (name of patient). What do we need to work on today?” He already knows how much I exercise and everything.
The Conditions of Engagement Form a Safe Therapeutic Container
The conditions of engagement work in concert to form a safe therapeutic container for the therapeutic relationship to manifest (Fig. 2). The foundational components of the container – the bottom and the walls – are represented by the cornerstone conditions being present and being receptive. Being present is the foundation that allows the other conditions to unfold, while being receptive provides the structure that enables pertinent information to be gathered. There is more of a personal aspect to being genuine and being committed; the degree to which either condition is established is reliant upon individuals’ uniqueness and circumstances. Essentially, the conditions of engagement set the tone for “being” with other and self, representing the dynamic intent to engage that both physiotherapist and patient bring to the relationship.