Understanding the therapeutic alliance in stroke rehabilitation.

Purpose: The quality of the therapeutic alliance between a client and their clinician is thought to play an important role in healthcare but there is limited research about this concept in stroke rehabilitation. This study explored the core components of a therapeutic alliance and the factors perceived to impact on its development in a stroke rehabilitation unit. Methods: Interpretive description methodology was used to gather and synthesise participants' experiences of their therapeutic relationships. Ten individual client interviews and one clinician focus group were conducted. Data was were analysed using conventional content analysis. Results: A therapeutic alliance appeared to consist of three overlapping core components: a personal connection, a professional collaboration, and family collaboration. Clients valued these components to different degrees and priorities could change over time. Alliance breakdowns were perceived to stem from a clinician's incorrect assumptions about their client's relationship preferences or lack of responsiveness to their needs. Recovery of the alliance seemed to depend on the strength of the pre-existing relationship and steps taken to repair it. Conclusions: Establishing and maintaining a therapeutic alliance appears to be an individualised and complex process. A clinician's ability to use their personal attributes therapeutically, and professional skills flexibly, appeared integral to relationship quality. IMPLICATIONS FOR REHABILITATION Developing therapeutic relationships requires a person-centred and sometimes family/whānau-centred approach. The judicious use of self-disclosure may achieve emotional proximity and yet maintain professional boundaries. Maintaining relationship health requires a proactive approach to detect and manage relationship disruptions.