Therapeutic Alliance with Youth with Mild Intellectual Disability or Borderline Intellectual Functioning: A Scoping Review

BackgroundThe therapeutic alliance (TA) is the bond between a patient and a physiotherapist during collaboration on recovery or training. Previous studies focused on the TA between physiotherapists and patients of the general population. Little information exists on whether this is similar in the demanding environment of elite athletes. The aim of this study was to investigate the components of TA between elite athletes and physiotherapists.MethodsTen elite athletes and ten physiotherapists were interviewed using one-on-one semi-structured interviews between June 2020 and October 2020. Athletes were included if they competed at national or international championships. Physiotherapists had to treat elite athletes on a regular basis. Interview questions were based on TA components of the general physiotherapy population. The interviews were transcribed and coded using inductive thematic analysis.ResultsThe analysis resulted in an elite athlete TA framework which consists of nine themes and ten subthemes that could influence the TA. The nine themes are trust, communication, professional bond, social bond, elite athlete, physiotherapist, time, pressure and adversity, and external factors. This showed that the TA consists of bonds on different social levels, depends on the traits of both elite athletes and physiotherapists, and can be positively and negatively influenced by the external environment. The influences from the external environment seem to be more present in the elite athlete TA compared to the TA in the general physiotherapy setting. Multiple relations between themes were discovered. Trust is regarded as the main connecting theme.ConclusionThis study provides a framework to better understand the complex reality of the TA between elite athletes and physiotherapists. Compared to the general physiotherapy setting, new themes emerged. The created framework can help elite athletes and physiotherapists to reflect and improve their TA and subsequently improve treatment outcomes.

ObjectiveStudies indicate that users can establish a therapeutic alliance (TA) with digital health interventions. However, research examining how TA unfolds in digital settings and its unique facets compared to conventional TA remains limited. This qualitative study aimed to explore and validate preliminary quantitative findings suggesting three distinct themes unique to eHealth TA.MethodsQualitative data were collected from users of a digital parent training program aiming to explore participants' general experiences with the program. Semi-structured double-blind interviews were conducted (n = 16), and responses to open-ended questions from a larger sample of users were collected (n = 64). Data were thematically analyzed using the six-step framework outlined by Braun and Clarke.ResultsIn the deductive thematic analysis all three eHealth TA themes were identified – Sense of Relatedness (SR), Application-Induced Accountability (AIA), and Perceived Emotional Investment (PEI), along with the three sub-themes of conventional TA (Goal, Task and Bond). Two eHealth TA themes (SR, AIA) were fully represented in participant's responses, while one (PEI) was only marginally validated. Regarding conventional TA, Goal and Task were fully represented, while Bond was only marginally validated. Validation of eHealth TA themes was further supported by the analysis of the open-ended questions.ConclusionsFindings reinforce prior research, indicating that TA in digital health settings unfolds in distinct ways, and underscoring the need for further exploration of eHealth TA's unique characteristics. Additionally, the study emphasizes potential advantages of employing double-blind methodology in qualitative studies.

The therapeutic alliance (TA) is considered one of the founding pillars of a therapeutic approach. Its breakdown is a complex phenomenon affecting both patients and therapists. The breakdown of a TA involves dynamics of withdrawal or confrontation, or both. This article focuses on patients' experiences of TA breakdown through interviews. What do patients have to say about behaviors that are antinomic to the therapeutic process? How do they understand the breakdown of TA-in a hospital setting or in private care? Is a resolution possible? Analysis of these interviews enables us to draw up a preliminary map of typical situations experienced by patients and the reasons that led them to break off the TA. Methods This study is part of a qualitative social science approach. In the first stage, 5 interviews were carried out by a researcher with experience in psychiatry with people affected (all women) by a breakdown in TA. The data collected was then transcribed, analyzed, grouped by theme, compared by theme, reorganized, merged and prioritized. Results The analysis highlighted five key themes in the factors leading to TA breakdown: the power of professionals, the relationship as symbolic violence, the act of care, the functioning of care institutions and the repair of the alliance. A central element in the discourse of the patients interviewed is the violence provoked by the lived experience of an asymmetry of power between them and the psychiatric setting. Faced with this situation, the patients gradually implement strategies of influence to reduce their powerlessness and adapt the care context to their needs, such as withholding information or lying. These narratives call into question the validity of psychiatric acts of care, and invite us to question the epistemological determinants that led to these standards and acts of care in the first place. Discussion In psychiatric institutions, these results suggest that the determinants of TA are, in fact, not insignificantly linked to power issues at multiple levels. Maintaining or breaking a TA is part of a sociological register in which patients recognize themselves as dominated, stigmatized and marginalized. In this context of oppression, concealing or manipulating the truth appear as necessary and licit acts to escape from situations experienced as unjust and confining. Taking a step back, this type of reaction is not new; it's part of the development of the epistemology of the dominated, a movement in social science theorizing the construction of knowledge among people and groups experiencing domination, and where resistance to oppression constitutes a subversive act of lucidity. Not surprisingly, their perspectives are in the minority, as they also reflect the minority social position of the people who practice them. Conclusion The preservation, or repair, of a solid TA is a priority for any therapeutic relationship. In this context, sensitizing psychiatric staff to the limits of the biomedical-positivist paradigm with which the psychiatric ethos and habitus are deeply imbued could be a welcome prelude to integrating certain points of view from the epistemology of the dominated into the therapeutic relationship. Welcoming these minority perspectives (for practitioners, not patients), has the potential to nurture genuinely new understandings in the TA dynamic, and to (re-)create TA dynamics based first and foremost on the humanity that connects us all, and less on the category to which we belong.

Therapeutic alliance is a core component of patient- and family-centered care, particularly in the setting of advancing cancer. Communication approaches used by pediatric oncologists to foster therapeutic alliance with children with cancer and their families are not well understood. To identify key oncologist-driven facilitators associated with building and sustaining therapeutic alliance in the setting of advancing pediatric cancer and to develop a framework to guide clinical practice and future investigation of therapeutic alliance. In this qualitative study, serial disease reevaluation discussions that occurred in the clinic, inpatient hospital, or off campus via telephone were recorded among pediatric oncologists, patients with high-risk cancer, and their families across 24 months or until death, whichever occurred first, from 2016 to 2020. This analysis focused on recorded discussions for pediatric patients who experienced progressive disease during the study period. Content analysis was conducted across recorded dialogue to derive inductive codes and identify themes. Participants were patient-parent dyads for whom a primary oncologist projected the patient's survival to be 50% or less, all family members and friends who attended any of their recorded disease reevaluation conversations, and their oncologists and other clinicians who attended the recorded discussions. A total of 33 patient-parent dyads were enrolled and followed longitudinally. From this cohort, 17 patients experienced disease progression during the study period, most of whom were female (11 [64.7%]) and White (15 [88.2%]) individuals. For these patients, 141 disease reevaluation discussions were audio recorded, comprising 2400 minutes of medical dialogue. Most children (14 [82.4%]) died during the study period. A median of 7 disease reevaluation discussions per patient (range, 1-19) were recorded. Content analysis yielded 28 unique concepts associated with therapeutic alliance fostered by oncologist communication. Ultimately, 7 core themes emerged to support a framework for clinician approaches associated with optimizing therapeutic alliance: human connection, empathy, presence, partnering, inclusivity, humor, and honesty. In this qualitative study, pediatric oncologists used diverse communication approaches associated with building and deepening connections across advancing illness. These findings offer a framework to support clinical and research strategies for strengthening therapeutic alliance among pediatric oncologists, patients, and families.

BackgroundDespite the promising benefits of self-guided digital interventions for adolescents recovering from concussion, attrition rates for such interventions are high. Evidence suggests that adults can develop therapeutic alliance with self-guided digital interventions, which is in turn associated with intervention engagement. However, no research has examined whether adolescents develop therapeutic alliance with self-guided digital interventions and what factors are important to its development. Additionally, social presence—the extent to which digital encounters feel like they are occurring in person—may be another relevant factor to understanding the nature of the connection between adolescents and a self-guided digital intervention, though this has yet to be explored.ObjectiveThis qualitative study explored the extent to which adolescents recovering from concussion developed therapeutic alliance and social presence during their use of a self-guided digital mindfulness-based intervention. Additionally, this study aimed to determine factors important to adolescents’ development of therapeutic alliance and social presence with the intervention.MethodsAdolescents aged between 12 and 17.99 years who sustained a concussion were recruited from 2 sites: a pediatric emergency department up to 48 hours after a concussion and a tertiary care clinic over 1 month following a concussion to capture adolescents who had both acute and persisting symptoms after concussion. Participants (N=10) completed a 4-week mindfulness-based intervention delivered through a smartphone app. Within the app, participants listened to audio recordings of mindfulness guides (voice actors) narrating psychoeducation and mindfulness practices. At 4 weeks, participants completed questionnaires and a semistructured interview exploring their experience of therapeutic alliance and social presence with the mindfulness guides in the intervention.ResultsThemes identified within the qualitative results revealed that participants developed therapeutic alliance and social presence by “developing a genuine connection” with their mindfulness guides and “sensing real people.” Particularly important to the development of therapeutic alliance and social presence were the mindfulness guides’ “personal backgrounds and voices,” such that participants felt more connected to the guides by knowing information about them and through the guides’ calm tone of voice in audio recordings. Quantitative findings supported qualitative results; participants’ average score for therapeutic alliance was far above the scale midpoint, while the mixed results for social presence measures aligned with qualitative findings that participants felt that the mindfulness guides seemed real but not quite as real as an in-person connection would.ConclusionsOur data suggest that adolescents can develop therapeutic alliance and social presence when using digital interventions with no direct human contact. Adolescents’ development of therapeutic alliance and social presence with self-guided digital interventions can be bolstered by increasing human-like qualities (eg, real voices) within interventions. Maximizing therapeutic alliance and social presence may be a promising way to reduce attrition in self-guided digital interventions while providing accessible treatment.

The patient-clinician therapeutic alliance is an important aspect of high-quality cancer care. However, components of the therapeutic alliance in adolescents and young adults (AYAs, aged 12-39 years) with cancer have not been defined. To identify components of and barriers to the therapeutic alliance between AYAs, caregivers, and clinicians from the perspective of all key stakeholders. In this qualitative study, semistructured in-depth interviews with patients, caregivers, and clinicians were conducted from 2018 to 2021 with no additional follow-up, with content analysis of resulting transcripts. Participants were recruited from Dana-Farber Cancer Institute, Kaiser Permanente Northern California, Kaiser Permanente Southern California, and an online cancer support community (Cactus Cancer Society). Eligible participants were English- or Spanish-speaking. Eligible patients were aged 12 to 39 years with stage IV or recurrent cancer. Eligible caregivers cared for an AYA living with advanced cancer or one who had died within 5 years. Eligible clinicians routinely provided care for AYAs with cancer. Perspectives on therapeutic alliance. Interviews were conducted with 80 participants: 23 were patients (48% were female; 78% were White), 28 were caregivers (82% were female; 50% were White), and 29 were clinicians (69% were female; 45% were White). The mean (SD) age of patients was 29 (7.3) years. Interviews identified 6 components of therapeutic alliance: (1) compassion; (2) sense of connection; (3) clinician presence; (4) information sharing; (5) shared goals; and (6) individualization of care. While some domains were represented in prior models of therapeutic alliance, a unique domain was identified related to the need for individualization of the approach to care for AYA patients and their caregivers. Interviews also identified potential barriers to building the therapeutic alliance specific to the AYA population, including managing discordant needs between patients and caregivers and communication challenges at the end of life. This study identified core components and barriers to building therapeutic alliance in the AYA advanced cancer population from the perspective of all the key stakeholders in the relationship. A novel component highlighting the need for individualization was identified. This model enables a deeper understanding of how to build therapeutic alliance in the AYA advanced cancer population, which may guide clinician training and facilitate improved care for this vulnerable population.

Background The therapeutic alliance (TA) has emerged as a key principle in enhancing the quality of health and rehabilitation services. Purpose This study aimed to explore patient perspectives on the influence of TAs with practitioners during inpatient rehabilitation following spinal cord injury (SCI). Methods Using a qualitative methodology, (n = 18) in-depth interviews were conducted with inpatient participants. Interviews were transcribed verbatim and analyzed using reflective thematic analysis. The study was grounded in a social constructionist epistemology, employing theories of liminality and psychotherapy as theoretical frameworks. Results Patient narratives suggest TAs are central to the rehabilitation experience. Additionally, analysis of patient stories revealed that patients entered a state of liminality upon admission. The primary theme, “Control as Enabling: Transition, the Marge,” highlighted during rehabilitation, patients navigated an identity separation and transition phase central to liminal spaces. Where practitioners accommodated patients’ identity journeys, meaningful TAs were established, enhancing rehabilitation. Conversely, when control was constrained, TAs weakened, increasing identity risks. TAs were found to be instrumental in protecting and preserving pre-SCI identity as well as facilitating movement through the liminal phase. Conclusion This research underscores the significance of TAs in SCI rehabilitation, demonstrating their role in enabling patient control, safeguarding identity, and facilitating the potential exit from liminality. To address the unique needs of SCI patients, it is recommended that SCI practitioners receive specialized TA training and professional development.

We propose a model for how therapeutic strategy, alliance, and epistemic trust interact to foster or hinder therapeutic processes. Four individual mentalization-based treatment (MBT) sessions were subjected to an in-depth qualitative comparison and interpretative phenomenological analysis. Two sessions had high adherence and quality ratings, and two exemplified low evaluations. The sessions were from an MBT program for patients with borderline personality disorder. The high-rated therapists were more prone to strategically identify and investigate maladaptive patterns, were more challenging, and brought the patients out of their comfort zone. This therapeutic endeavour seemed to facilitate therapeutic alliance and a productive therapeutic process. Low-rated therapists seemed to be brought out of their own comfort zone (e.g. transferences/counter-transferences), and attempted to amend the relational atmosphere by being supportive. In these sessions, the therapeutic alliance seemed weak, and therapeutic progress was not observed. When therapists strategically and competently challenged problematic patterns, despite disclosing discomfort, alliance was strengthened. It seemed that a clear therapeutic strategy, and skilfull battling of the patients’ comfort zone, fostered the therapeutic process. We hypothesize that epistemic trust may develop as a product of a fruitful and persistent focus on tasks and goals in therapy.

12100 Background: Hospice is underutilized at end-of-life by patients with cancer. Among the barriers to earlier acceptance of hospice may be the perceived loss of the therapeutic alliance and emotional support provided by the oncology team once the hospice team starts care. With the growing utilization of telemedicine, we sought to understand patient, caregiver, hospice nurse, and oncologist perceptions of synchronizing home hospice visits by the hospice nurse with remote telemedicine visits performed by the oncologist in their clinic. Methods: Thirty-four newly enrolled hospice patients (age 57-90+; 20 female & 14 male; 28 white non-Hispanic,1 white Hispanic, 3 black/African American, 2 other; 19 married, 3 single, 3 divorced, 1 significant other, 7 widowed, 1 other) and 34 caregivers were consented to an IRB-approved study between 5/14/21-9/9/24. Home hospice nurse visits were coordinated with the oncologist’s clinic schedule and telemedicine visits were securely conducted through Epic MyChart functionality. Mixed methodology was utilized with patients, caregivers, hospice nurses and oncologists completing five-point Likert-scale surveys at baseline and subsequent serial surveys for patients and caregivers. Results: All groups rated improvement in overall communication. Likert scores for ease and quality of communication improved for oncologists (3.0 to 1.5) and nurses (2.0 to 1.0). Therapeutic alliance scores for patients and caregivers were stable and improved for oncologists (2.5 to 1.5) and nurses (2.0 to 1.5). Conclusions: Patients and caregivers expressed highly favorable ratings of hospice experience at baseline and improvement with telemedicine visits. There was no degradation in patient and caregiver therapeutic alliance scores, suggesting preservation of patient experience. Improvement among oncologists and hospice nurses was seen for both communication and therapeutic alliance scores once synchronous telemedicine hospice visits were instituted. These findings suggest that all four groups found value in oncologist-hospice patient telemedicine visits. Qualitative interviews and thematic analysis of caregivers’ impressions of the program continue to identify how better to support patients and caregivers during home hospice care. Quantitative results. Baseline Score Improvement in Score Median (IQR) Median (IQR) Patient Communication Overall 2.0 (1.25-2.75) 1.0 (0.5-1.0) Therapeutic Alliance Support received from oncologist 2.0 (1-3) 0.0 (-0.5-2.5) Caregiver Communication Overall 2.0 (1.75-3) 1.0 (0.0-1.0) Therapeutic Alliance Support received from oncologist 1.0 (1-3) 0.0 (0.0-0.0) Oncologist Communication Overall 3.0 (2-4.75) 2.0 (0.0-3.0) Therapeutic Alliance Connection 2.5 (2.0-3.0) 1.0 (0.0-2.0) Hospice Nurse Communication Overall 2.0 (2-2.75) 1.0 (0.0-1.0) Therapeutic Alliance Connection with patient & family 2.0 (1-2) 0.5 (0.0-1.0) IQR – interquartile range.

Objective:A positive therapeutic (or working) alliance has been associated with better outcomes for clients in the psychotherapeutic and traumatic brain injury (TBI) rehabilitation literature. The aim of this pilot study was to gain an understanding of the therapeutic alliance in community rehabilitation from the perspectives of adults with TBI and their close others who have completed a community rehabilitation programme.Method:This study used a constructivist, qualitative methodology which applied grounded theory analysis techniques. Using purposeful sampling, three pairs of participants (adults with TBI and close others) who had finished a community rehabilitation programme completed separate in-depth interviews which were transcribed verbatim and progressively analysed using a process of constant comparison.Results:A preliminary framework illustrating participants’ experience of a therapeutic alliance was generated, comprising three interconnected themes: being recognised as an individual, working together and feeling personally connected. All participants viewed being able to work together as important in their experience of community rehabilitation and described features that helped and hindered the alliance.Conclusion:These pilot study results demonstrate the importance of the therapeutic alliance to the rehabilitation experience of individuals with TBI and those close to them.

The aim of this study was to explore mothers' and public health nurses' (PHN) experiences with sleep problems in children aged 6 months to 3 years in Norway. Sleep problems in children are common, affecting their health and development, and their mothers' well-being. It is also the primary reason parents seek help in well-child clinics (WCC). However, there is limited knowledge regarding the experiences of these mothers and the public health nurses who consult them. Qualitative design. Four semi-structured focus group interviews were conducted: two with mothers (n= 14) who had children with sleep problems and two with public health nurses (n= 14) from well-child clinics. The Framework Method was used for analysing the interviews of mothers. Data from public health nurses were charted onto the analytical framework of maternal data to understand how or whether public health nurses addressed the issues raised by mothers. The study is reported according to the COREQ checklist. The analysis resulted in two main themes: 'therapeutic alliance' (categories 'alliance ruptures' and 'demanding negotiation process') and 'reorganisation of identity' (categories 'unfulfilled expectations' and 'internal tension conflicts'). Young children's sleep problems present challenges to new mothers due to failed expectations, negatively affecting their feelings as mothers and towards their children, and consequently the reorganising of maternal identity. Most mothers experienced unsatisfactory therapeutic alliances while seeking help from public health nurses because advice was considered overly general, contradictory and unsafe for their children. Public health nurses were mostly aware of the parental consequences of children's sleep problems, but many appeared unable to help because of limited time and knowledge. Public health nurses need to establish a therapeutic alliance and provide evidence-based knowledge and guidance on sleep problems while also considering women's reorganisation of identity when becoming mothers. Open Science Framework: osf-registrations-6ag38-v1 (https://archive.org/details/osf-registrations-6ag38-v1).

Self-guided mental health smartphone applications (apps) have the potential to increase access to evidence-based psychological interventions and reduce the burden on staff resources in strained mental health services. Within human-delivered therapy, the working relationship (therapeutic alliance) between the client and therapist is well studied and has been consistently linked to effective and engaging therapy. However, less is known about whether a digital therapeutic alliance exists, what its components may be, and how it can be fostered to improve engagement and adherence to smartphone applications. This study explored the experiences of users of a mental health app to better understand digital therapeutic alliance and how persuasive systems design may help us understand which features of app design influence this relationship. We conducted a qualitative study using semi-structured interviews with 13 participants who had recent experiences of using the STOP app which targets paranoia. Data were analyzed using framework analysis with therapeutic alliance and persuasive systems design as deductive theoretical frameworks. We constructed five dimensions of digital therapeutic alliance: 1) Humanness of the app, 2) Personal meaningfulness, 3) Progression towards goals, 4) How is it to use the app, and 5) Flexibility enhances relationship. Themes 1-4 map onto the existing dimensions of therapeutic alliance, and Theme 5 (Flexibility enhances relationship) provides the context within which a digital therapeutic alliance forms. Persuasive systems design features were found to reinforce and enhance aspects of digital therapeutic alliance. This study provides valuable insight into the existence of digital therapeutic relationships (alliance) and its dimensions. From our findings, there are indicators that digital therapeutic alliance is a digital analogue of therapeutic alliance and is enhanced by persuasive features of the app. Findings from this study could be used to inform the design of mental health apps to enhance their capacity to foster digital therapeutic alliance with users, with the supposition that as with the traditional therapeutic alliance, its digital counterpart is also conducive to better efficacy in mental health apps.

The objective of this study is to conduct a comprehensive review literature researches examining the relationships between therapist mindfulness and the therapeutic alliance and therapeutic relationship. To this end, articles published on the subject between 2006 and 2024 were identified through a search databases PubMed, Web of Science, Medline, Taylor & Francis Online, Science Direct, Turkish Psychiatry Index, ULAKBIM and TR Index databases using the identified keywords. After rigorous evaluation process based on the inclusion and exclusion criteria, 25 quantitative, qualitative and mixed methods studies were included in this study. Mindfulness practices were mostly conducted under the guidance of the Mindfulness-Based Stress Reduction programme, which includes a variety of practices such as body scanning, hatha yoga, sitting meditation, daily mindfulness practices and conscious relaxation exercises. The results showed that mindfulness supports the therapeutic alliance in a very consistent way. It was found that therapists' acceptance of themselves and their clients increased with the practice of mindfulness, and that clinicians with high levels of mindfulness were able to maintain the therapeutic alliance more effectively. It was found that clinicians who practised mindfulness on a weekly basis were able to engage in a stronger therapeutic alliance than those who did not practise at all, and clinicians with a high frequency of weekly practice were able to engage in a stronger therapeutic alliance than those with a low frequency of practice. In addition, mindfulness practice was found to support the therapeutic alliance through several mechanisms, such as reducing countertransference, increasing empathy, and increasing tolerance of negative emotions. In conclusion, the findings of this review suggest that increasing therapists' levels of mindfulness would be a highly worthwhile endeavour in terms of developing a strong therapeutic alliance.

BackgroundMost conventional treatment for musculoskeletal conditions continue to show moderate effects, prompting calls for ways to increase effectiveness, including drawing from strategies used across other health conditions. Therapeutic alliance refers to the relational processes at play in treatment which can act in combination or independently of specific interventions. Current evidence guiding the use of therapeutic alliance in health care arises largely from psychotherapy and medicine literature. The objective of this review was to map out the available literature on therapeutic alliance conceptual frameworks, themes, measures and determinants in musculoskeletal rehabilitation across physiotherapy and occupational therapy disciplines.MethodsA scoping review of the literature published in English since inception to July 2015 was conducted using Medline, EMBASE, PsychINFO, PEDro, SportDISCUS, AMED, OTSeeker, AMED and the grey literature. A key search term strategy was employed using “physiotherapy”, “occupational therapy”, “therapeutic alliance”, and “musculoskeletal” to identify relevant studies. All searches were performed between December 2014 and July 2015 with an updated search on January 2017. Two investigators screened article title, abstract and full text review for articles meeting the inclusion criteria and extracted therapeutic alliance data and details of each study.ResultsOne hundred and thirty articles met the inclusion criteria including quantitative (33%), qualitative (39%), mixed methods (7%) and reviews and discussions (23%) and most data came from the USA (23%). Randomized trials and systematic reviews were 4.6 and 2.3% respectively. Low back pain condition (22%) and primary care (30.7%) were the most reported condition and setting respectively. One theory, 9 frameworks, 26 models, 8 themes and 42 subthemes of therapeutic alliance were identified. Twenty-six measures were identified; the Working Alliance Inventory (WAI) was the most utilized measure (13%). Most of the therapeutic alliance themes extracted were from patient perspectives. The relationship between adherence and therapeutic alliance was examined by 26 articles of which 57% showed some correlation between therapeutic alliance and adherence. Age moderated the relationship between therapeutic alliance and adherence with younger individuals and an autonomy support environment reporting improved adherence. Prioritized goals, autonomy support and motivation were facilitators of therapeutic alliance.ConclusionTherapeutic Alliance has been studied in a limited extent in the rehabilitation literature with conflicting frameworks and findings. Potential benefits described for enhancing therapeutic alliance might include better exercise adherence. Several knowledge gaps have been identified with a potential for generating future research priorities for therapeutic alliance in musculoskeletal rehabilitation.

The therapeutic alliance (TA) has the highest predictive value concerning the success of psychotherapy. The presented study aimed to explore how the presence of an interpreter affects the TA when working with trauma-affected refugees. Semi-structured interviews were conducted with seven psychologists working in an outpatient clinic specialized in mental health care for migrant and refugee patients with trauma-related mental health problems in Denmark. Interviews were transcribed verbatim and analyzed using a structuring content analysis approach. TA has been described as a dynamic therapist-interpreter-patient alliance triangle consisting of three distinct but highly intertwined and mutually influential dyadic alliances. Specific factors affecting the quality of the TA were identified, e.g., interpreter being emotionally attuned yet not overly involved; interpreter being barely visible yet present as a human being. Characteristics of trauma-affected refugee patients affecting the TA formation were also identified, e.g., a high level of personal distrust, different understandings of mental disorders and psychotherapy, stigmatization, perceptions of authorities. The presence of interpreters was perceived ambivalently and the formation of a good TA seems to be a balancing act. Based on the findings, recommendations for forming and maintaining a good TA in interpreter-mediated psychotherapy are provided.