This study is the first to explore the quality of the therapeutic alliance between patients and chiropractors in The Netherlands as perceived by both patients and chiropractors. The measurement instrument used in this study assessed how both patients and chiropractors experienced collaboration in reaching agreement on treatment goals and treatment strategies to achieve their goals and how they perceived their affective bond. The results showed that, immediately after the third consultation, both patients and chiropractors perceived the quality of their working relationship overall to be very positive. Results on the quality of the three separate elements of the alliance showed that both patients and chiropractors slightly more often experienced the presence of the affective bond than collaboration in reaching consensus on treatment goals and treatment strategies. However, poor agreement was shown to exist between perceptions of patients and chiropractors of the quality of their alliance, both overall, and on the three elements of the alliance separately. Neither the chiropractors’ gender nor their years of experience, nor gender matching between chiropractor-patient pairs was shown to influence perceptions of patients on the quality of the alliance significantly.
Whereas the results of this study are encouraging in that patients felt that their interaction with their chiropractor was very good, they do not permit chiropractors to sit back and relax. The therapeutic alliance is a dynamic and developing process of collaboration between the patient and clinician and its strength often fluctuates during the course of care [2, 29]. Understanding how clinician and patient factors, such as their present mood, preoccupation with personal issues and severity of symptoms, as well as situational factors, such as excessive workload, lack of time, waiting time, and delays in improvement, may cause fluctuations in the strength of the therapeutic alliance over time is imperative for chiropractors. To maintain a positive alliance between the patient and the chiropractor, both parties have to demonstrate a commitment to collaborate during the course of the treatment for however long that takes [2, 29]. Important to note in this respect is that although previous research has confirmed a positive and consistent association between therapeutic alliance and clinical outcomes, the term ‘association’ does not indicate that there is a causal relationship between the two [36]. However, a recent study in the field of physical therapy and rehabilitation found a clear dose–response effect between the therapeutic alliance and clinical outcomes. Outcomes were better when interventions were combined with enhanced therapeutic alliance applications, compared to a limited application of factors that have been shown to enhance the therapeutic alliance [14].
The small differences between patients’ views and chiropractors’ views might disguise the fact that there was poor agreement between these perceptions. The results showed that chiropractors and patients had very different perceptions of the same working relationship. A lack of agreement between patient views and therapist views is consistent with the literature in psychotherapy. It was suggested that patient perceptions are more predictive for clinical outcomes compared to therapist perceptions, on the basis that patient perceptions were shown to remain more stable over time compared to therapists’ perceptions [4, 6, 29]. However, no studies were conducted to test this hypothesis.
One could argue that the poor agreement between patients’ and chiropractors’ views is the most important finding of this study for clinical practice. Chiropractors should be aware of this possible dissonance and should verify their views with the patient, especially concerning views on setting treatment goals and treatment strategies. Dissonance in agreement on treatment goals and treatment strategies can jeopardise patient management, especially in the case of chronic disease, where self-management and self-efficacy from patients are essential [26].
Somewhat surprisingly, the results in the present study did not demonstrate any difference between the varying years of experience as a chiropractor on patients’ perceptions of the quality of any of the elements of the therapeutic alliance. In a study in psychotherapy, which used the same version of the WAV-12 as the present study [29], interactions with respect to agreement on treatment strategies with therapists with over 20 years of experience were perceived significantly less positive compared to interactions with less experienced therapists (10–19 years). Besides a possible difference in education, it was postulated by the authors that a more experienced therapist may more frequently work on ‘an automatic pilot’, and spent less time and energy on discussing treatment strategies as to how to achieve the treatment goals with their patients. Working on the ‘automatic pilot’ may also be true for more experienced chiropractors. At the same time, as a result of patients being informed better and having their own ideas about health, experienced chiropractors may have consciously or unconsciously adapted their patient management to accommodate for more collaboration, thereby improving the therapeutic alliance.
Studies on empathy and communication in relation to the therapeutic alliance [24, 37] found that female physicians displayed more empathy and active collaboration than male physicians, both of which behaviours are considered to improve the strength of the alliance. Although there might be differences in displaying empathy and active collaboration between male and female chiropractors, this study showed that patients’ perceptions of the quality of the alliance did not differ for male and female chiropractors. This lack of difference might partly be explained by the fact that chiropractic care is considered as alternative medicine in The Netherlands and is still fairly unknown to many patients. Chiropractors will have to make an effort to explain and promote their care and might, therefore, be more motivated to engage and collaborate with the patient, independent of their gender. Educational differences between medicine and chiropractic might play a role as well. Historically, chiropractic has always advocated a holistic approach, in which patients are attended to in their whole identity as opposed to the former disease-centred approach in medicine. Chiropractors might, therefore, be more experienced in practising patient-centred care, which involves empathic and collaborative behaviour. Their training may thus diminish any gender differences in displaying empathy that was seen amongst male and female physicians. Furthermore, many chiropractors in The Netherlands decided to become a chiropractor because of their personal experience with chiropractic as a patient. It has been suggested that to improve empathic behaviour a clinician should be a patient himself [18]. Having started as a patient may be an advantage for many chiropractors, both female and male, in displaying empathy.
Some of these reasons could also explain the unexpected lack of difference in patients’ perceptions of the therapeutic alliance between gender-matched and unmatched chiropractor-patient pairs. Other explanations for this lack of difference might be that patients who have a clear preference for a female or male chiropractor can often be booked with the chiropractor of their choice since many chiropractic clinics have both female and male chiropractors working in the clinic. Consulting a chiropractor of the gender of their preference may give patients a more positive stance in the working relationship. Recommendation by an acquaintance or family member might also positively influence the patient’s stance in the working relationship at the start of the treatment, irrespective of factors such as gender or age of the chiropractor. Although this could be pure coincidence, the freedom of the patient to choose a chiropractor of the gender of preference may explain why almost two-thirds of the analysed working relationships in this study involved gender-matched chiropractor-patient pairs.
There are several limitations to this study, which potentially compromise the external validity of this study. Firstly, participation in this study was on a voluntary basis. Chiropractors who advocate patient-centred care and have good communication skills could be overrepresented in this study. Secondly, questionnaires were sent to the participating chiropractors in advance, which allowed them to read the questions in advance, and as a result, allowed them to give their best performance to the patient with respect to the alliance. Thirdly, perceptions were observed at one moment in time and were, therefore, influenced by the mood of the participant at that particular moment. In addition, patients who did not trust their chiropractor not to open the envelope and read their perceptions may have reported more positive perceptions. Furthermore, since all questions were scored in the same direction, participants may have failed to pay close attention to the questions and may have answered all items in the same way. The use of a questionnaire, which was developed in the field of psychotherapy, might be a further limitation. In the absence of a better alternative, the Working Alliance Inventory (WAI) has been proven valid and usable in physiotherapy settings [32]. Nevertheless, participants in the present study found some questions confusing or ambiguous. Noteworthy in this respect is that more than 10 % of patients did not complete all questions as requested. Particularly issues related to the quality of the affective bond between the patient and chiropractor were left unanswered. Although no feedback was requested from the participants, several patients reported questions exploring the quality of the affective bond to be irrelevant or inappropriate. And even though it could be argued that these questions were not relevant, some questions are considered less applicable in a chiropractic setting. Similar responses were found in a physiotherapy setting, and the authors suggested to develop a more conceptually sound measure of the therapeutic alliance for use in physiotherapy [32]. Furthermore, several chiropractors commented on the choice of response scale. The current options (seldom to always) were found inappropriate and not applicable to rating perceptions, and suggestions were made using options as to how much the participant agreed with each statement (strongly disagree to strongly agree). This modification was applied in a study on perceptions of the quality of the therapeutic alliance in a primary care setting, along with some modifications in the phrasing of the statements, and proved useful [10]. As in any observational study, confounders could not be fully controlled for in this study. Specific patient or chiropractor characteristics could have influenced the results. Some patients might have had severe symptoms, unintentionally influencing their perceptions more negatively. Female and male chiropractors might have treated patients with different levels of symptoms, different levels of cognitive ability, and of different ages, which could all have influenced perceptions on gender and experience. These differences, however, reflect daily practice and were, therefore, considered acceptable.
One important recommendation for further research is to develop a uniform instrument to assess the quality of the therapeutic alliance, with an appropriate response scale that could be used in primary care settings. This uniform instrument should be translated and validated for use in different countries. The second recommendation for research is to further investigate the level of agreement on treatment goals and treatment strategies to achieve these goals between patients and chiropractors. In the present study, only perceptions of collaboration in reaching agreement were studied. It would be useful for clinical practice to conduct a study examining to what extent patients and chiropractors agree on treatment goals and treatment strategies, as was conducted for patients with diabetes and their physicians and showed poor levels of agreement [26].