Strategies for Clinical Reasoning: Building the Therapeutic Alliance

Making the transition from academia to the professional world poses a unique challenge to those entering the field of healthcare. Translating the information learned during lectures, clinical rotations, and practical exams into clinical application is often daunting. However, these concepts can help you create a framework that will make clinical reasoning a little bit easier.

History Taking

The subjective intake is approximately 80 percent of your evaluation. This is the opportunity to not only gather necessary medical information and design a plan of care, but also to learn about the patient from a more holistic perspective. Prognostic factors for individuals with musculoskeletal pain include recognizing the patient’s belief system as well as their individual values and expectations.1

Learning more about the individual will help better guide you throughout the examination and the continuum of care. The initial interview can be a powerful intervention as it can set the tone for the overall patient experience. Efficient history-taking and a detailed physical examination can yield:2

  • Positive therapeutic effect
  • A short-term decrease in pain
  • Decreased catastrophization
  • Improved functional mobility
  • Decreased sensitivity to pressure

The history taking alone produced the most significant changes when compared to the physical examination.2

Therapeutic Alliance

Building a therapeutic alliance is more than just establishing a sound rapport with your patient. It includes analyzing other elements that can contribute to the patient/practitioner relationship:

  • According to Martin et al., it is a “general construct that usually includes in its theoretical definition the collaborative nature, the affective bond, and the goal and task agreement between patients and clinicians.”3
  • Higher levels of the therapeutic alliance were associated with greater improvements in the perceived effect of treatment, function, and reductions in pain and disability.4
  • An optimal therapeutic alliance is achieved when the patient and therapist share beliefs concerning the goals of treatment and view the methods used to achieve these as efficacious and relevant.5


The way we communicate with our patients is crucial. We must learn how to speak—and listen—to different types of people and understand what effective communication looks, sounds, and feels like for them. These are some common characteristics of effective communication:

  • Active listening involves paying complete attention to what another person is saying. It involves listening closely while showing interest and, importantly, refraining from interrupting.
  • Non-verbal communication, also known as body language, involves maintaining eye contact, avoiding looking at the clock or yawning (or other signs of boredom or time constraints), sitting adjacent or across from the patient rather than standing overhead and looking down upon them, keeping a relaxed and open posture, and nodding your head to affirm your understanding of what is being said.
  • Clear and succinct language is important to consider in both verbal and written forms of communication. Health literacy plays a critical role in a patient’s ability to participate in decisions made about their health. Using plain language that is easy for patients to understand in lieu of complicated medical jargon will increase the patient’s ability to engage in dialogue with you, contribute to the conversation, and walk away with a solid comprehension of their plan of care.
  • Conveying empathy allows the patient to feel seen and understood, while also opening up an important pathway to trust, which can increase adherence to the therapy plan. Empathy can be conveyed by expressing an understanding for their feelings, repeating back what the patient has said, and inquiring about non-verbal cues that express anxiety, overwhelm, or fear.

Teaching and Learning Styles

Recognition of the differences in each patient’s learning style is only one part of the equation. We must also be dynamic in our teaching style and adjust our clinical presentations to different personalities. Utilizing a patient-centered approach will be extremely helpful throughout the episode of care.


The words we use when speaking with a patient are impactful and can convey distinct messaging, which then influences the rehabilitation process. Specific phrases or words can connote a hopeless or inevitable situation in the patient’s mind. Examples of such phrases include:

  • Degeneration
  • Wear and tear
  • Bone on bone
  • Slipped disc
  • Chronic degenerative changes

It is critical that we choose our language carefully and learn how to frame our words differently to help the patient understand what they are experiencing. We must consider and prioritize the patient’s perception.6

Motivational Interviewing

Motivational interviewing is a collaborative conversation between the patient and the clinician to strengthen an individual’s motivation and commitment.7 Motivational interviewing is comprised of specific communication techniques, including:

  • Open vs. closed questions—When given the opportunity, patients can have the chance to elaborate more on what they are currently experiencing.
    • Open-ended questions
      • Allow for freedom of response
      • Are perceived as a display of personal interest and care
      • Help understand what the patient is experiencing and perceiving
      • Encourage the patient’s active involvement and influence
    • Closed-ended questions
      • Are biased for clarification
      • Can help confirm suspected hypotheses
  • Affirmations—Positive statements made to the patient demonstrate interest and understanding of what the patient is experiencing.
  • Reflective Listening—This can allow the patient to share their personal experiences and can also further test initial working hypotheses. Further insights can help confirm the patient’s belief system and understanding of their perception.
  • Summarizing—We synthesize the data and learn how to use a ‘funnel approach’ to generate initial working hypotheses, which will be tested during the rest of the evaluation and throughout physical therapy.

Patient Experience

Application of these concepts and principles will help guide the clinician and continue to enhance the patient experience. The patient experience is continuous from the time the patient enters your clinic and throughout the examination and duration of physical therapy until discharge from the current episode of care.

Generally, patients want to know the answers to these four questions:8

  • What is wrong with me?
  • How long will it take to get better?
  • What can I do to get better?
  • What can you do about it?

By better understanding your patient, you can better address questions like these and empower your patieny to take an active role in their rehabilitation plan.

To learn more about patient engagement and motivational interviewing, MedBridge offers these courses to broaden your motivational interviewing skill set, boost patient engagement, improve your clinical reasoning abilities, and enhance the patient experience.

  1. Bialosky, J. E., Bishop, M. D., & Cleland, J. A. (2010). Individual expectation: an overlooked, but pertinent, factor in the treatment of individuals experiencing musculoskeletal pain. Physical Therapy90(9), 1345–1355.
  2. Louw, A., Goldrick, S., Bernstetter, A., Van Gelder, L. H., Parr, A., Zimney, K., & Cox, T. (2021). Evaluation is treatment for low back pain. The Journal of Manual & Manipulative Therapy29(1), 4–13.
  3. Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68(3), 438–450.
  4. Ferreira, P., Ferreira, M., Maher, C., Refshauge, K., Latimer, J., & Adams, R. (2013). The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain, Physical Therapy, 93(4), 470–478.
  5. Ardito R. B. & Rabellino D. (2011). Therapeutic alliance and outcome of psychotherapy: historical excursus, measurements, and prospects for research. Frontiers in Psychology, 2 (270), 1-11.
  6. Stewart M. & Loftus S. (2018). Sticks and stones: the impact of language in musculoskeletal rehabilitation. Journal of Orthopaedic & Sports Physical Therapy. 48(7), 519–522.
  7. Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change, 3rd edition. Guilford Press: New York City.
  8. Gifford, L. (2021). Aches and pains. Philippa Tindle.