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The Impossibility of Client–Therapist “Match”: Implications and Future Directions for Multicultural Competency
Abstract
Extensive research has examined the influence of client–therapist racial, ethnic, or cultural match on outcomes in therapy. Further, many narrative reviews have summarized the literature in this area, and several meta-analytic reviews have examined the strength of the influence of client–therapist match. The present narrative review builds on previous studies by discussing several critical issues in this literature. In particular, we add to the extant literature reviews by contextualizing the challenges of defining and measuring client–therapist match given the possible broad range of diverse intersectional identities. As matching is not always possible, recommendations for working with clients of a different cultural background are discussed. Suggestions for multicultural competence training are included. We also provide a case example of how intersectionality of identities can inform the therapeutic context. The current article provides updated insights into the client–therapist match literature and emphasizes specific recommendations for education, training, and supervision.
... Being "lost in translation" can cause clients to feel like outsiders in therapeutic settings (Costa, 2010). This sense of otherness has negative implications for treatment outcomes; similarities between the racial, ethnic, and cultural identities of therapist and client have been associated with positive therapeutic outcomes and lower dropout rates (Ertl et al., 2019). ...
... Despite the challenges that may arise during multicultural therapy, recent findings have emphasized the importance of having multicultural training for clinicians (Costa & Dewaele, 2019;Ertl et al., 2019;Rivera et al., 2021;Rolland et al., 2021). A review of multicultural training within the marriage and family therapy field highlighted the need for training that went beyond the content of a culture and equipped clinicians with relational skills needed to engage in multicultural relationships (Rivera et al., 2021). ...
... In this case study, and in any situation when working with a client using their non-native language, much of the client's original narrative is metaphorically written in a language that the client and therapist do not share. While linguistic differences have been cited in previous literature as a potential barrier to developing a strong therapeutic alliance (Ertl et al., 2019;Kokaliari et al., 2013), multicultural competency skills can compensate for the challenges posed by varying linguistic resources between a therapist and their clients (Ertl et al., 2019). It is imperative to take a curious stance in order to cultivate a safe environment for collaboration with bilingual clients. ...
As the bilingual Spanish-speaking population in the United States (U.S.) steadily rises (U.S. Census Bureau in Language spoken at home, https://data.census.gov/cedsci/profile?q=United%20States&g=0100000US, 2020), the need for systemic therapists who are competent in working with Spanish-speaking clients also increases. While it is unrealistic to require all mental health practitioners to be bilingual English and Spanish speakers, systemic therapists can improve their understanding of the impact that clients’ native language can have on the therapeutic process. In this paper, we synthesize concepts from narrative therapy and linguistic relativity to provide non-Spanish-speaking clinicians with a unique perspective of case conceptualizations and therapeutic interventions for clients who natively speak Spanish. A clinical vignette is presented to illustrate the practical application of linguistic relativity informed systemic therapy. Potential theoretical and clinical implications of this treatment suggestion are explored.
... Little is known about effects of racial and ethnic differences or similarities between evaluators and evaluees (Kois & Chauhan, 2016). Looking to research on therapist-client relationships, racial and ethnic matching of therapists and clients does not improve treatment outcomes (Ertl et al., 2019;Erdur et al., 2003;Shin et al., 2005). Black clients are more likely than white, Asian American, and Latinx clients to prefer a Black therapist (Cabral & Smith, 2011;Ilagan & Heatherington, 2022). ...
... However, this research is limited by an ethnic gloss, or overly simplistic labels to describe ethnic or cultural groups that minimize heterogeneity within groups (e.g., Asian American vs. Japanese American; Trimble & Bhadra, 2013); assumptions therapists and clients from the same culture hold similar views aligned with cultural expectations; and inconsistencies in defining and identifying race, ethnicity, and culture (Ertl et al., 2019). Exact therapist-client (or evaluator-evaluee) matches are unlikely given the myriad factors influencing intersectional identity. ...
... Exact therapist-client (or evaluator-evaluee) matches are unlikely given the myriad factors influencing intersectional identity. An intersectional approach (Ertl et al., 2019) promoting cultural humility (Lekas et al., 2020) and thoughtfully considering race and ethnicity can improve mistrust stemming from differences. ...
Existing forensic mental health assessment (FMHA) models do not address the role of race or ethnicity in data collection, interpretation, report writing, or testimony. This omission impedes gathering information relevant to the forensic question. By expanding the scope of 12 of 38 established principles of FMHA, we propose “race-informed FMHA,” a culturally responsive model that systematically assesses the impact and relevance of race, ethnicity and intersectional identities. We identify culturally responsive tools and approaches to present identity-related information. We suggest ways to increase evaluators’ fluency in discussing race and ethnicity—their own and others’—with implications for research and practice.
... Da vi spurte informantene om hvordan det psykiske helsetilbudet til norskfødte med innvandrerforeldre kunne bli bedre, var det mange av informantene som etterspurte terapeuter med minoritetskompetanse og ønsket flere terapeuter med minoritetsbakgrunn. Basert på argumentasjonen om interseksjonalitet som Ertl et al. (2019) presenterer, mener vi at økt kunnskap om sosial makt, kulturell trygghet og terapeutisk flerkulturell kompetanse kan vaere nyttig i møte med norskfødte med innvandrerforeldre (for mer informasjon, se blant annet Ertl et al., 2019, Fors, 2018, Ramsden, 2002, Richardson, 2010og Soto et al., 2018. På bakgrunn av tidligere forskning på kulturell mistillit og stigma rundt psykiske lidelser vil vi hevde at klienter med mindre tillit til terapeuter og psykologisk behandling kan ha nytte av mer tid til relasjons-og alliansebygging (Safran & Muran, 2000;Trinh et al., 2019). ...
... Da vi spurte informantene om hvordan det psykiske helsetilbudet til norskfødte med innvandrerforeldre kunne bli bedre, var det mange av informantene som etterspurte terapeuter med minoritetskompetanse og ønsket flere terapeuter med minoritetsbakgrunn. Basert på argumentasjonen om interseksjonalitet som Ertl et al. (2019) presenterer, mener vi at økt kunnskap om sosial makt, kulturell trygghet og terapeutisk flerkulturell kompetanse kan vaere nyttig i møte med norskfødte med innvandrerforeldre (for mer informasjon, se blant annet Ertl et al., 2019, Fors, 2018, Ramsden, 2002, Richardson, 2010og Soto et al., 2018. På bakgrunn av tidligere forskning på kulturell mistillit og stigma rundt psykiske lidelser vil vi hevde at klienter med mindre tillit til terapeuter og psykologisk behandling kan ha nytte av mer tid til relasjons-og alliansebygging (Safran & Muran, 2000;Trinh et al., 2019). ...
Background: Focus on minority perspectives and cultural factors in therapy has increased in recent years. This study aimed to examine experiences of undergoing psychotherapy among Norwegian-born with immigrant parents to assess possible challenges in receiving mental health care. Method: We conducted semi-structured interviews with 13 informants from multicultural backgrounds who had undergone psychotherapy. Transcripts were analysed using hermeneutic-phenomenological thematic analysis. Results: We identified three themes: 1) What do they know about living between two cultures? 2) When the therapist gets it wrong, and 3) Seeking help when stigma is attached to psychotherapy. Conclusion: Our findings suggest that Norwegian-born with immigrant parents have several unique experiences that may be important when undergoing psychotherapy. More research is needed to investigate the significance of these experiences for psychotherapy and how therapists can best meet these experiences. Keywords: multicultural, ethnic minority, psychotherapy, therapeutic multicultural competence, therapeutic alliance
... Similarly, Zane and Ku (2014) found that ethnic matches between patients and therapists did not impact self-disclosure and treatment outcomes in psychotherapy. In addition to these null findings, another significant limitation in ethnically matching patients to clinicians concerns the difficulties which may be encountered in finding patient-therapist matches (Ertl et al., 2019). Finally, some patients are less likely to seek a clinician from the same ethnic group due to confidentiality concerns (Mill et al., 2011) and others may prefer clinicians from a dominant ethnic group they do not belong to because they perceive them to be more qualified (Keshet, 2019). ...
... A three-dimensional model of multicultural competence was developed to address cultural sensitivity training for professionals, including clinicians. It includes: (a) knowing and understanding group history, (b) awareness of one's beliefs, biases, and attitudes, and (c) developing sufficient skills to provide culturally sensitive intervention and assessment (Sue et al., 1982;Ertl et al., 2019). This starts with five recommendations for educational institutions that train clinicians and includes: (1) create systems to identify and address bias and discrimination, (2) reduction of bias and discrimination must start with the leaders, (3) ensure comprehensive curricula that address the reduction of bias, (4) ensure critical diversity among professionals, and (5) create an environment that encompasses respect, inclusion, and equity. ...
A primary consideration in rehabilitation is the compatibility between clinicians and patients, where cultural diversity is a defining feature for both. The intricacies of cultural considerations in patient-clinician matching are heightened in areas of conflict and civil unrest. This paper presents three perspectives of the significance of cultural considerations in such assignments: patient-centred approach - prioritizing patients’ preferences; professional-centred approach - clinicians’ safety, social-emotional, and training needs; and utilitarian approach - what is best for the majority. A case study from an Israeli rehabilitation clinic is presented to exhibit the multifaceted considerations in patient-clinician matching within areas of conflict and civil unrest. The reconciliation of these three approaches in the context of cultural diversity is discussed, suggesting the benefit of a case-by-case strategy involving combinations of the three. Further research could examine how this might feasibly and beneficially optimize outcomes for all in culturally diverse societies in times of unrest.
... Although a direct relation between racial matching and treatment outcomes is not always evident (e.g., Ruglass et al., 2014), racial matching is associated with lower rates of firstsession dropout and longer therapy duration (Kim & Kang, 2018). Despite the valuable observation that race is too broad of a category to measure therapist-client cultural similarity (Ertl et al., 2019), This document is copyrighted by the American Psychological Association or one of its allied publishers. ...
Understanding Black therapists’ educational decisions contributes to increasing Black therapists’ representation and accessibility. The present study explored the role of racial identity attitudes, demographic factors, and motivations for becoming a therapist (e.g., personal experiences, altruism) in predicting membership in the subfields of counseling, clinical psychology, and social work. Black therapists (N = 129) were surveyed about their career trajectories and personal characteristics. Predictors of subfield membership were examined using multinomial logistic regression. Black therapists who endorsed the racial identity status of internalization and those who were motivated by family problems were more likely to be social workers or counselors than clinical psychologists. Attending a historically Black college/university and being motivated by professional altruism predicted membership in social work relative to clinical psychology, whereas those who were motivated by the experience of personal problems were more likely to be clinical psychologists than counselors or social workers. We conclude that Black therapists’ career decision making appears to be consistent with the expressed values of psychotherapy subfields. Understanding Black therapists’ motivations and career trajectories can inform recruitment and retention efforts within psychotherapist training and employment.
... Although matching a patient and a clinician in all characteristics is impossible because of the number of identities one possesses (Ertl et al. 2019), the cross-cultural dyad brings to light very specific differences. All participants in this study identified the "therapist" as an immigrant. ...
What happens when the therapist and client have experienced migration, and both have the same country of origin? Interesting dynamics can take place in the therapy room, which remain relatively unexplored in the systemic literature. The complexity of the migration process, and the resources and possible traps in this specific setting, are illustrated with clinical vignettes and discussed in the light of a recurring question: How can the therapist use their own experience to attune to the client?
The integration of somatic approaches in art therapy can counter the trauma of microaggressions. By adopting a power-from-within stance, art therapists can facilitate sessions for clients to affirm their LGBTQIA+ identities while resisting the impact of discrimination. This article, co-written by an art therapist and client, provides lived experience examples of somatic art therapy: Somatic Experiencing® integrated with body tracing, and sensorimotor art therapy (the Clay Field®). The authors concur that somatically integrated art therapy has helped replace automized behavioral patterns based on fear with behavioral choices that emerged from a place of safety. Implications for therapeutic alliance and power dynamics within art therapy sessions are explored as tenets of body-based self-reflection.
Keywords: Cultural humility; LGBTQIA+; sensorimotor art therapy; somatic art therapy; therapeutic alliance
There is an increasing demand for psychotherapy among ethnic minority populations. Yet, there is not adequate evidence that empirically supported therapies (ESTs) are effective with ethnic minorities. Ethical guidelines suggest that psychotherapies be modified to become culturally appropriate for ethnic minority persons. Conceptual approaches have identified interdependence, spirituality, and discrimination as considerations for culturally sensitive therapy (CST). However, there is no more empirical support for the efficacy of CSTs than there is for the efficacy of ESTs with ethnic minority populations. The chasm between EST and CST research is a function of differences between methods and researchers in these 2 traditions. Specific recommendations for research collaboration between CST and EST researchers are offered.
Mental health treatments can be more effective when they align with the culture of the client and when therapists demonstrate multicultural competence. We summarize relevant research findings in two meta‐analyses. In the meta‐analysis examining culturally adapted interventions, the average effect size across 99 studies was d = 0.50 (0.35 after accounting for publication bias). In the second meta‐analysis on 15 studies of therapist cultural competence, the results differed by rating source: Client‐rated measures measures of therapist cultural competence correlated strongly (r = 0.38) with treatment outcomes but therapists’ self‐rated competency did not (r = 0.06). We describe patient considerations and research limitations. We conclude with research supported therapeutic practices that help clients benefit from modifications to treatment related to culture.
Given today’s racial diversity and the ongoing racial tensions in our communities as a result of police shootings of unarmed Black men, terrorist acts in the United States and globally, and expressions of racism and xenophobia in the political arena, it is essential for psychologists to be culturally competent. Four diverse faculty members engaged in a self-study of their multicultural teaching practices to explore the challenges inherent in participating in authentic race dialogues. In this article, we discuss the findings from our independent and collective analysis of faculty narratives and provide recommendations for facilitating honest and courageous race dialogues in graduate psychology training.
Clients’ nonattendance in therapy poses a significant threat to the effective delivery of mental health services at university counseling centers. As such, researchers have investigated processes related to clients’ nonattendance in an effort to increase treatment utilization and treatment outcomes. However, there is a paucity of research testing the impact of the therapist on clients’ nonattendance patterns. Additionally, it is unknown whether therapists vary in the nonattendance of their racial/ethnic minority (REM) and White clients. Therefore, the present study sought to identify therapist effects in client nonattendance rates, and examine between-therapist disparities in REM and White clients’ nonattendance patterns. Data for this study consisted of 275 REM and 341 White clients seen by 21 therapists at a large university counseling center. Results indicated that therapists accounted for 14% of the variability in clients’ nonattendance. Additionally, therapist effects in nonattendance due to clients’ REM status were identified, suggesting that therapists are a significant source of racial/ethnic disparities in clients’ nonattendance. REM clients’ nonattendance rates were higher compared to White clients for some therapists, but not others. Clinical implications and future research are discussed.
The present study is the first to apply Trawalter, Richeson, and Shelton’s (2009) stress and coping framework to qualitatively examine interracial interactions in initial sessions of psychotherapy. The sample included 22 dyads: 15 therapists of color administering various treatment modalities to 15 treatment-seeking non-Latino White (NLW) patients and a comparison group of 7 intraracial (NLW-NLW) dyads. In Phase 1, videorecordings of the first session of treatment were analyzed using inductive thematic analysis (TA) to describe patient and therapist behaviors. In Phase 2, a deductive TA approach was used to interpret and cluster those dyadic behaviors according to Trawalter et al.’s (2009) framework. NLW patients paired with therapists of color made more efforts to bridge differences and more often questioned the therapist’s professional qualifications compared with those matched with NLW therapists. Therapists of color made more self-disclosures than NLW therapists and maintained a more formal stance, compared with NLW therapists. The deductive TA operationalized 4 of Trawalter and colleagues’ (2009) coping responses within a therapeutic framework. Findings highlight the ability of therapists’ of color to engage positively with their NLW patients even in the face of challenges to their expertise and credibility.
An ethnic gloss is an overgeneralization or simplistic categorical label used to refer to ethnocultural groups such as American Indians, Asian Americans, Hispanics, African Americans, and other nationalistic or indigenous groups where unique cultural and ethnic differences found among group members are ignored. An ethnic gloss presents the illusion of homogeneity where none exists, and therefore may be a superficial, almost vacuous, categorization that provides little or no information on the existence of numerous subgroups characterized by distinct lifeways and thoughtways. It is a sorting device that has little to do with the richness and cultural variation within ethnocultural groups that also guides a group member's thoughts, feelings, and behaviors. Furthermore, use of a broad ethnic gloss to describe an ethnocultural group can generate biased and flawed scientific research outcomes, and may promote stereotypes. Such sweeping references to ethnocultural groups are gross misrepresentations, and use of an ethnic gloss can violate scientific tenets concerning external validity, the ability to generalize findings across subgroups within an ethnic category, and erode any likelihood of an accurate and efficient replication of research results. This entry provides examples of the use of ethnic gloss, and recommendations for more adequate identification and sampling of research participants from diverse ethnocultural groups.
The short answer to this complex question is “It depends”. It may help to consider the rationale behind ethnic matching. When counsellor and client share the same cultural background, empathic understanding and self-disclosure are more easily facilitated. However, most counsellors and counsellor trainers are white, middle-class people whose values and communication styles may differ from those of ethnic minority clients especially those of lower socio-economic status. Thus white counsellors may unwittingly engage in cultural oppression by imposing Western values on ethnic minority clients. Further, ethnic minority clients, because of a historical exposure to, and current experiences of, racism may have a damaged ethnic or racial identity which would hinder the development of a therapeutic alliance with a white counsellor. Thus understanding the client’s ethnic or racial identity development is important in cross-cultural counselling.
Traditional counselling theories have frequently been criticised for their lack of multicultural relevance, yet even today many UK counsellors assume a prevailing white (and middle class) culture. This summary of research findings in multicultural counselling has had to rely entirely on evidence from the USA, since to my knowledge very little comparable work has been done in this country.
This section gives a brief overview of the current research, emphasizing its lack of agreed findings and the limitations in methodology. It then focuses on three major questions, asking whether counsellor race/ ethnicity, explicit multicultural counsellor education and current research affect the counselling process and outcome.
