Power and the Therapeutic Relationship: Considerations for Physiotherapists

If you’re a fan of the Marvel Universe or, like me, are surrounded by fans you will recognize that quote from Spiderman. You may or may not identify with the message, but as a practicing physiotherapist you probably should. That’s because every day, in every interaction we have with our patients, physiotherapists lever our power and influence.

The purpose of this article is to enhance physiotherapists’ understanding of:

• How power relates to shared decision-making, patient-centered care and consent
• The sources of physiotherapists’ power in the therapeutic relationship
• Factors that affect the power imbalance between patients and physiotherapists
• Strategies to minimize the imbalance, and reasons why it can never truly be equalized
• Stimulate some thought about how power is manifested in their practice and strategies they can use to manage it.

To be fair, the concepts of power and power imbalance are not new to physiotherapists. Many, if not all of us, were cautioned from early in our physiotherapy education to be thoughtful about power and to minimize the power imbalance between physiotherapist and patient, but at the same time maintain professional boundaries and relationships with our patients. Resources such as the College of Physiotherapists of Alberta’s Therapeutic Relationships Resource Guide¹ reinforce these early messages and draw attention to the potential problems and risks that power imbalances pose to physiotherapists and their patients.

That’s because physiotherapists and other regulated health professionals are in positions of authority and power relative to our patients and do not always manage that power well. Part of the issue may be that physiotherapists place considerable importance on the value of benevolence and “extraordinarily less importance” (relative to other low-rated values) on power.⁸ As Nosse and Sagiv noted, “the pursuit of power is not compatible with acting benevolently, the value goal held most important by therapists.”⁸ This leads to some interesting questions.

• Do physiotherapists perceive themselves as having power within the therapeutic relationship and understand the sources of that power?
• Do physiotherapists ignore or dispute power dynamics because they don’t value power?
• What problems could arise if a physiotherapist thinks that they have effectively shared power and the patient disagrees?
• How could a lack of awareness of power lead to issues in the therapeutic relationship?

Underlying these questions is the fact that physiotherapists don’t necessarily do a good job of explicitly discussing power, using other terms instead, and failing to identify that power is an “implicit part of the therapeutic alliance, shared decision-making or patient-centered care. All of these related concepts, even by their terms, imply a negotiation of power” (Miciak M 2019, personal communication, May 27). While there is a growing body of research related to the therapeutic alliance, shared decision-making, and patient-centered care, there are surprisingly few physiotherapy publications that directly study power or how physiotherapists and their patients experience power imbalances. While some research suggests that both groups are aware of the power dynamics at play in the therapeutic relationship,⁴ anecdotal evidence from the world of regulation and complaints indicates that power and the management of appropriate boundaries are not universally understood.

Physiotherapists can look at publications from the areas of political science, psychology and sociology to better understand the sources of positional power. Seminal work from French and Raven identified several bases of power:⁵

• Reward and coercive power relate to the ability of a one individual to provide rewards or punishments to another individual.
• Referent power relates to an individual’s identification and emulation of a powerful individual or group and the individual’s desire to be part of that group.⁵

While these aspects of power may be factors in some therapeutic relationships, legitimate and expert power are arguably more common sources of power for physiotherapists.

• The concept of legitimate power is that one party has a valid right to prescribe behaviour or beliefs for another person even though they cannot apply sanctions or punishments.

In practice, this power stems from the patient’s values, their acceptance that the physiotherapist has a right to influence their behavior, and that the patient has an obligation to accept this influence. Legitimate power relates to culture and cultural values and reflects authority imparted due to age, intelligence, physical characteristics, caste, and the role or office an individual holds.⁵ The historical hierarchical power often afforded to health-care professionals by some groups is an example of legitimate power (e.g. “do what the doctor says” mentality).

• Expert power relates to the unique knowledge and expertise that an individual holds.

In practice this relates to the patient’s assessment of the physiotherapist’s knowledge and expertise relative to the patient’s own. Patient’s may also assess power based on the characteristics of the information a physiotherapist provides “such as the logic of the argument or the ‘self-evident facts’.”⁵ In other words, the unique knowledge and education that physiotherapists possess and the patient’s perception of the validity of the information the physiotherapist shares are sources of power.^5,6

Other factors that contribute to physiotherapists’ positional power include:⁶

• Their intimate knowledge of the patient and their problems, which is not reciprocated by similar disclosures from the physiotherapist.
• The patient’s dependence on the physiotherapist to address a health problem, which may include considerable pain, decreased function, or fear.
• The vulnerability that arises due to that dependence, pain, decreased function and fear.

The relative power that a physiotherapist possesses will vary depending on the position they hold, their age and experience, expertise and communication skills. Similarly, not all patients will perceive power imbalance to the same degree. Factors which might influence the patient’s experience of power imbalance include their:

• Socio-economic status
• General literacy and educational background
• Health literacy
• Cultural background and cultural norms regarding health, and the roles of patient and health professional
• Severity of illness and level of physical, mental and emotional dependence on others
• Autonomy (i.e., the degree to which they are deciding to pursue physiotherapy, ability to select the physiotherapist of their choice).

Take a moment to reflect on the different sources of power outlined and how they relate to you and your patients. What sources of power do you possess? Are some of your patients more likely to perceive a power imbalance than others?

In the absence of evidence to the contrary, physiotherapists are encouraged to err on the side of caution, assuming patients experience a significant power imbalance within the therapeutic relationship and making intentional efforts to share power. A primary way to do so is by adopting robust patient-centered care practices. One key is to focus on addressing the issues that the patient identifies as priority, rather than those which the physiotherapist identifies as therapeutically important or assumes to be a priority. As Eisenberg aptly describes, clinicians and patients alike need a collective shift towards the perspective that the physiotherapist is the expert on the condition and its treatment, and the patient is expert on their experience of the condition, their values and priorities.⁶ This also entails an acceptance that “the [physio]therapist’s role [is] in activating the patient’s own resources, in being a motivator, and an educator…”⁷

Physiotherapists can work to achieve this goal by:

• Acknowledging the patient’s life outside of rehabilitation, conveying the message that they are seen as a “person first”⁴
• Being attentive during treatment⁴
• Educating patients about their role in decision making and the importance of their input as experts in their values and preferences⁸
• Providing information and education about the patient’s condition and recovery prognostics,⁸ and doing so using verbal communication that is “at the patient’s level”⁴
• Providing decision aids and other tools to encourage patient participation in treatment planning⁸
• Using appropriate personal disclosures to build the therapeutic relationship⁴

Even the simple act of positioning one’s self at an equal or lower physical level during the patient interview can send an important message.⁴

Enmeshed in this discussion is the concept of consent. For patients to achieve a measure of power and autonomy in the therapeutic relationship, the knowledge gap between patient and physiotherapist needs to be bridged. By doing so, the patient gains an understanding of what they are agreeing to and shifts from accepting treatment because it’s what the physiotherapist recommends, to agreeing to a treatment plan with an understanding of what and why they are providing their consent. It’s no coincidence that this knowledge is what is required in order to provide a valid informed consent.  

This means that the physiotherapist must provide the patient with comprehensive information regarding their assessment findings, proposed treatments and how they will address the patient’s problems, the risks and benefits of receiving treatment including the risks of declining treatment, and the patient’s right to withdraw consent at any time.⁹ This information must be shared in a way that is understood by the patient, and should include additional materials and approaches (brochures, videos, other sources of information) that ‘fit’ the patient’s information needs and support their understanding. Finally, the physiotherapist must check that the information was understood.

The list of actions that physiotherapists do every day for valid therapeutic reasons, but which could be misunderstood by patients is long, as has been previously discussed. Using robust patient education and consent practices can help to mitigate the risk of misunderstanding and ensure that the patient has been empowered as an active participant in their care.  Not surprisingly, fundamentals of shared decision making, consent and patient-centered care all help improve the balance of power within the therapeutic relationship and help to reduce the risks of power being used inappropriately.

However, these efforts need to be paired with the realization that because a patient seeks the physiotherapist’s assistance to manage their condition and the physiotherapist has the knowledge to do so, the balance of power will always rest with the physiotherapist, regardless of their efforts.⁶ In fact, even when physiotherapists think they are successfully engaging in shared decision making, collaboration and patient-centered care, studies suggest that patients may perceive otherwise,⁸ or may have difficulty understanding and applying the concepts in practice.¹⁰ This does not mean that the physiotherapist should stop trying, simply that they must realize that even as they engage in efforts to do so, they are unlikely to ever achieve a true equalization of power and should not assume that they have.

Arguably, the root of the 2018 amendments to the HPA is a recognition that health professionals are in positions of power relative to their patients, paired with a growing awareness that sexual assault is not about sex or attraction, but rather about power.¹¹ Keeping this in mind, it becomes easier to understand the risk that health care professionals can pose to patients if they choose to use their power inappropriately. By being aware and accepting of power in the therapeutic relationship, physiotherapists can intentionally act to minimize the imbalance while simultaneously using their powers for good, like their favorite superheroes.

Key Points:

• Power is an underlying component of common care processes, including consent, shared decision making and the development of the therapeutic relationship.
• The power imbalance between patients and physiotherapists is inevitable, but may vary from person to person, physiotherapist to physiotherapist.
• The physiotherapist’s job is to recognize this power imbalance exists, work to reduce the imbalance, and realize they will never fully eliminate it.
• With this in mind, the physiotherapist has the responsibility to make sure they do not use their positional power inappropriately during interactions with patients.

Take a moment to consider your practice or discuss with your colleagues what this information means for you:

• What factors in your practice contribute to the power imbalance between you and your patients? What do you do to try to minimize the imbalance?  
• What strategies could you implement to minimize the power imbalance?  
• Are there clinical practices that you engage in that could be misinterpreted by patients?
• What steps have you taken to ensure that the physiotherapy purpose of these activities is clear to the patient and that you have the patient’s consent to engage in the activity?

Page updated: 03/01/2024