Beyond the dyad: negociating the working alliance in intercultural return-to-work rehabilitation

PURPOSE: Research on the therapeutic alliance (TA) has largely focused on therapist-patient dyads, overlooking the complexity of multi-actor and intercultural contexts such as work rehabilitation. This study examines how the TA is constructed and negotiated within a multidisciplinary return-to-work program involving immigrant workers in Québec. MATERIALS AND METHODS: Using a qualitative case study design, the study combines participant observation and semi-structured interviews with seven injured immigrant workers. RESULTS: Our findings suggest that the therapeutic alliance may be better understood as a stable interpersonal relationship but rather as a dynamic, multi-level process embedded within clinical, institutional, and sociocultural contexts. The bond of trust emerges as a composite construct, including rapport, perceived competence, perceived allegiance, trust in the system, and therapist trust in the patient. While tasks tend to be a site of relative consensus, goals-particularly return to work-are often contested, reflecting divergent expectations between workers and institutions. These tensions are further shaped by intercultural dynamics, migration trajectories, and systemic constraints. CONCLUSIONS: The study contributes to reconceptualizing the TA as an ecosystemic and negotiated process, extending beyond dyadic models. It highlights the need for reflexive clinical practices, greater transparency regarding institutional mandates, and increased attention to cultural and structural factors in rehabilitation.