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Shop Talk: Therapeutic Alliance

August 16, 2021 • Behavioral Health • Sheila Schindler-Ivens

Shop Talk is a newsletter published by The Evidence Workshop, LLC.  
It helps clinicians integrate the best research evidence into front-line practice. 

A former student and evidence aficionado recently posted to Twitter, “Do bad dad jokes help or distract from therapeutic alliance?” Followed by, “Q: What do you call lunch meat on the floor? A: Below knee!”

I replied, “Bad dad jokes always help, especially puns. Q: What do you call a fish with two knees? A: A two knee fish.”

By the time we both stopped groaning, I began to wonder, “What exactly is therapeutic alliance? I don’t remember learning it in PT school.” With a little background work in PubMed, here’s what I learned:

  1. The MeSH term, therapeutic alliance, was added in 2019.
  2. It seems the term originated with our colleagues in counseling and psychotherapy.
  3. Per the definition assigned in MeSH, therapeutic alliance is

“A relational factor in counseling that includes three dimensions: goal consensus between counselor and client, collaboration on counseling-related tasks, and emotional bonding. It is referred to as the working alliance between a therapist and a client in psychotherapy and closely correlated with positive client outcomes.”

I guess that means that good things happen when patients and clients:

  • agree on goals,
  • work together to achieve them, and
  • form an emotional connection.

With a quick peek at UpToDate, I found a review on therapeutic alliance in psychiatry written by Andrew Skodol and Donna Bender. After introducing the topic, the authors discussed problems in therapeutic relationships (e.g. confrontation, strain, rupture) and the relationship between therapeutic alliance and specific treatment modalities such as cognitive-behavioral therapy, medication, and hospitalization. It cites 40 articles, and the literature review is current as of July 2021. Of note, I was unable to find an article in UpToDate on therapeutic alliance in physical rehabilitation.

Since this is the first mention of UpToDate in Shop Talk, here’s a little primer.

UpToDate is a repository of reviews, clinical updates, graphics, and other evidence-based tools for healthcare decision making. Because it is written for clinicians, content is more sophisticated than WebMD. It employs top-down curation and editing, which makes it more like a textbook than Wikipedia.

  • Don’t know how to define therapeutic alliance?  Look it up in UpToDate.
  • Never treated anyone with patellofemoral pain? UpToDate provides a review with 100 citations that summarizes risk factors, clinical evaluation, treatment, follow-up, complications, and more.
  • Haven’t heard of polymorphous light eruption? Me neither. But UpToDate summarizes the condition, explains how it’s managed, and discusses prognosis. The article has 68 citations.

Before you start Googling UpToDate, be aware of this. Unlike PubMed, UpToDate is not free to the world. It is a subscription service. If you work in a university or large hospital system, your employer probably subscribes, and you should be able to access it through your library website. But if you are in a small, freestanding clinic that does not have a library system, access may be more challenging. The American Physical Therapy Association (APTA) does not provide UpToDate to its members. However, their Rehabilitation Reference Center is a good alternative. Your local public library may be able to help if they have access to library holdings at the public universities in your state. If you don’t know how to find this stuff, ask your librarian. Remember, they love hearing from you.

Returning to the initial question about dad jokes and therapeutic alliance, I still think it’s a good idea as long as you and your patient

  • agree that puns are fun,
  • work together to discover them, and
  • form an emotional bond in the process.

Thanks for reading. If you enjoy our content, tell a friend, visit our website, and support our mission at If someone forwarded this to you, please consider subscribing by emailing “add me to the list” to [email protected]. You’ll get one or two e-mails each month. We don’t sell contact information.

As always, you can learn more from the links below.

  • Former student and evidence aficionado, Benjamin Dorow, DPT, OCS, tweets at @LyleDorow
    • Follow him on Twitter to learn something new every day. He has challenged himself to read a research article every day for 365 days. He tweets brief summaries of everything he reads. How’s that for ambitious and generous?
  • APTA members can access the Rehabilitation Reference Center
    • You will need your member ID and password.
  • Students, faculty, and staff at Marquette can access UpToDate by following these simple steps:  
    • Go to
    • Click on Articles & Databases.
    • Under Choose a topic / discipline, select Physical Therapy.
    • Click on U in the a, b, c list.
    • Scroll down to find UpToDate from UpToDate.  Click to start your search.
    • Note, you must be on campus or logged onto the VPN to gain access.  Remember, Marquette is paying for the subscription for our community.
  • Learn more about MeSH terms. It’s a 4-minute read.

Sheila Schindler-Ivens

Dr. Sheila Schindler-Ivens is a licensed physical therapist who earned her PhD in Rehabilitation Science from the University of Iowa and completed a postdoctoral fellowship at the Feinberg School of Medicine at Northwestern University. Dr. Schindler-Ivens joined the faculty in the Dept. of Physical Therapy at Marquette University in 2005. She directs an independent research...

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