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Strengthening the Therapeutic Relationship: Identifying and Addressing Implicit Bias

Apr 11, 2022

Everyone has biases. There are biases that you are aware that you hold, and biases that you may not recognize. The biases that you are unaware of are particularly challenging as they may not align with your outward beliefs and can inadvertently impact your personal and professional relationships.   

Let’s consider an example. Alexander and Adeela are both patients in the Canadian health system.  

Alexander is a white, able-bodied, cisgendered male (meaning his gender identity is the same as his sex assigned at birth.) His body type matches societal expectations of a healthy body, and he speaks with an Anglo-Canadian accent. Because of these discernable characteristics, Alexander is less likely to experience barriers to care and says his interactions with health providers have been positive. He has a family physician who he consults with regularly and he doesn’t hesitate to see health professionals when he’s sick or injured.

As a patient who identifies as a visible minority, wears a head-covering and has a higher Body Mass Index (BMI), Adeela has painful memories of her interactions with health providers that often make her reluctant to seek treatment. Because of the common misperception that people in larger bodies cannot also be healthy, Adeela says health providers would rarely ask about her activity level or athletic goals. She recalls other instances when health providers made incorrect assumptions about her background and lifestyle based on her physical appearance. She often waits to see if an illness or injury will go away on its own, instead of seeing a health professional.

These stories of disparities in patient care are not uncommon in the Canadian health care system. A 2020 study on confronting racism in the health care system explores how race, culture and religion are “persistent determinants of health inequities.” The study further explores how the unconscious or implicit bias of health professionals can play a significant role in the level and quality of care that a patient receives.

The disparities for Indigenous peoples within the health system are also well documented. Indigenous peoples are more likely to experience lower health outcomes, due in part to systemic and structural racism across the Canadian health system, as detailed in research from the University of Manitoba and the Ministry of Health in British Columbia.

What is Implicit Bias?

Implicit bias refers to beliefs, attitudes and associations that are present but not consciously recognized. As the study on racism in the health care system states, implicit biases are rooted in “a system of beliefs or stereotypes that influence our attitudes, behaviours, and decisions, unconsciously.”

Examples of implicit bias include equating being overweight to being unhealthy, or the idea that Black patients have a higher pain tolerance and require less pain management – an assumption that is well documented by the Association of American Medical Colleges and other organizations. These pervasive societal stereotypes can distort your ability to make clinical decisions based solely in evidence or to see your patient as a unique individual and determine meaningful goals of treatment.

People’s biases are shaped by a variety of factors including how they were raised, where they were raised, their household beliefs and their own lived experiences. Not all biases are bad, but the ability for physiotherapists to recognize their biases within the context of the therapeutic relationship is critical.

One study of the necessary conditions of engagement for the therapeutic relationship in physiotherapy highlighted the importance of positive patient experiences saying the “therapeutic relationship between patient and physiotherapist is a central component of patient-centred care and has been positively associated with better physiotherapy clinical outcome.”

How to Identify Implicit Bias

Health providers are often unaware of their implicit biases and subsequently do not understand how these biases can negatively impact the therapeutic relationship. Because implicit bias exists in the subconscious mind, it takes a great deal of self-awareness and reflection to identify these biases and actively work against them.

Harvard has an Implicit Association Test (IAT) that can help you identify attitudes or beliefs that you may not know you have. The IAT covers a variety of topics including gender, race, weight, age, religion, and disability.

Studies have shown that by identifying and recognizing their biases, health providers can improve the health care experience for patients and ultimately lead to more successful outcomes.  

For example, research from the Global Journal of Health Science concluded that “self-reflection, coupled with deeper community engagement and continuing professional development, would enhance physiotherapy practice [...] in the future.”

As part of your continuing professional development, we encourage you to actively engage in the process of identifying bias and work to understand the cultural intricacies of the communities you serve.

Tips to Address Implicit Bias:

  • Ask your patients open-ended questions. When you elevate their voice, you can learn from their experiences and strengthen the therapeutic relationship. Allow enough time when booking assessments for a complete subjective exam.
  • See each patient as an individual rather than a stereotype. Challenge long-held assumptions and beliefs you hold based on a patient’s body size, age, ethnicity, religion or gender.
  • Take time to understand the patient’s concerns and goals as well as the barriers they may face in achieving those goals.
  • Listen without judgement and focus on what is being said instead of how something might be said. Allow the patient to answer without interruption.
  • Become engaged in and learn about different communities and cultures. Expand your network or attend conferences and learning sessions that celebrate and promote diversity.

Remember that any steps you take to foster a culture of patient safety in your practice – including identifying and addressing your own biases – will ultimately contribute to quality care and help improve patient outcomes.


This article is part of a series in support of the College’s Equity, Diversity and Inclusion initiatives. We look forward to sharing more posts in the coming year that explore pertinent societal issues, inspire meaningful conversation, and promote equity and inclusion.

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