The most consistent and robust predictor of outcome in psychotherapy is the quality of the client-therapist relationship (Lambert, 2013). While we know that therapists’ overall competence and client factors, such as motivation, are relevant and important to treatment, the client-therapist relationship is considered essential to effective treatment, at least in most therapies (Norcross & Lambert, 2011). This may be particularly true for those of who work with diverse clients, defined here as persons who identify or are identified by others as different from the prevailing dominant culture on the basis of race, ethnicity, culture, and/or other human diversity characteristics.
One prominent way of conceptualizing the therapy relationship is in terms of a working alliance (i.e., agreement on goals and tasks, and an emotional bond), a real relationship (i.e., perceptions that befit the other as a person and an ability to be genuine), and the configuration of transference/countertransference (i.e., distortions, displacements from the past brought into the relationship; Gelso & Hayes, 1998). In this brief paper we intend to highlight how the client-therapist relationship is particularly important in multicultural therapy and how each of these three dimensions of the relationship is relevant to it. We also discuss important therapist factors, such as knowledge, attitudes, and skills that foster the development and strengthening of the relationship. This paper is a continuation of a fruitful round-table discussion that the authors held at a recent APA conference. We have organized the content below in terms of the questions that were raised and discussed with the participants.
A few caveats. First we use the terms multicultural, diverse, and minority inclusively as described above. Second, we recognize that all people are socialized, cultural beings, so therapeutic interactions are inherently multicultural. We also recognize that for some dyads in therapy, race, ethnicity, culture, and other human diversity characteristics and experiences will be more relevant and more likely to impact the therapeutic relationship and, thus, the core of the work (e.g., a dyad in which the therapist is Euro-American and the client is African-American or dyads in which race relations and racism are central topics of discussion). Third, we acknowledge the critical importance of therapists’ ongoing commitment to developing knowledge and awareness of their identities and how they might be perceived by clients who are from various cultural backgrounds. Finally, although the relationship in multicultural therapy could be conceived of and defined from other theoretical perspectives, our focus in the current paper is to make connections with what we considered to be the traditional perspectives of the relationship.
The first question raised at the roundtable discussion was how one establishes therapeutic trust and rapport with an individual who is culturally different. In the discussion, it was noted that it is important to treat each client as an individual; thus, the therapist’s competence in assessment and intervention and ability to approach and engage clients will be key in establishing a relationship. For competent therapists, establishing an effective relationship in multicultural psychotherapy may not require significant changes from what they normally do successfully with other clients. However, at times, modifications in approach and timing may be necessary in order for the relationship to develop. In the working alliance, there is an emphasis on building trust, and, to an extent, on the importance of there being some level of a bond between the client and therapist. This is crucial to the relationship in multicultural therapy, and it may take a special sensitivity and patience on the part of the therapist for trust and mutual respect to develop with some clients. We believe that it is also important to explore the client’s perspective on the nature of therapy and the therapeutic relationship (through immediacy, for example) and to use this understanding to assess and meet the needs and expectations that the client brings to therapy. The emphasis in the working alliance on agreement is also crucial here, so that the client feels understood. While establishing the therapeutic relationship, it may be particularly important for the therapist to express openness to discussing the client’s experiences, including those that may be difficult or different for the therapist to hear, such as those involving bias, oppression, and racism. Validation of the client’s experience is critical at this stage. While therapist openness and validation is important throughout treatment, it seems essential early on, to help the client begin to explore and process painful and difficult experiences of a racial, cultural, or social nature. In the process of maintaining and strengthening relationships, therapists may need to regularly check in with clients to confirm their understanding of these experiences, with empathy and with respect for the cultural beliefs and perspectives, strengths, and resources that might be available or of value to their clients (i.e., family, religion, and community).
The second question was: What is the role of the therapist’s own identity and worldview in multicultural therapy? As mentioned above, therapists’ professional awareness of and competence surrounding issues of race and ethnicity, as well as power and privilege, seem fundamental to building therapy relationships (Helms & Cook, 1999). This is relevant for all therapists, since we are all socialized beings whose values, beliefs, worldviews, and expectations influence the formation and development of therapeutic relationships. Beyond self-awareness, therapists can remain cognizant that the interpersonal process during the therapy hour reflects a social microcosm, where social and economic tensions, inequities, injustices, and misunderstandings might be brought into the relationship and inform the process and outcome of treatment. Good therapists will empathize with their clients, continually check the accuracy of their understandings of clients’ circumstances and experiences, and work with patience and respect to forge relationships with clients in a way that reflects what Egan (2009) calls a “just society.” The therapist will need to multi-task: on the one hand, engaging in the traditional forms of assessment and relationship building inherent in all psychotherapy treatment; and, on the other hand, modeling openness about racial, cultural, and other differences, and sometimes probing clients about racial and cultural differences and the extent to which race and culture-based experiences are relevant to work in treatment.
Our collective experience tells us that for some clients racial, cultural, and other diversity factors may be central to the work, but for others these experiences may be peripheral or less relevant or central to the work in therapy. While knowledge about the plight and history of various racial and cultural groups in the U.S. is valuable, the therapist must be cautious not to generalize or stereotype the client as fitting a profile; the therapist can approach the minority client as an individual who may have internalized a set of values and beliefs that stem from various environmental sources including race, ethnicity, culture, and more. A focus on the client as an individual personality, developed psychologically, socially, and culturally through human relationships and experiences, might help the therapist better establish a genuine and affirming therapeutic relationship. The concept of the real relationship (Gelso, 2011) emphasizes the importance of each participant, client and therapist, to be “who I am” in therapy, with the other; the real relationship highlights the importance for both client and therapist in being able to be “who he/she is” in therapy, and for the two to be able to perceive each other in realistically ways that befit them. The real relationship thus emphasizes the value in treatment for participants to see each other authentically in a person-to-person “I/Thou” frame, without the distortions that come from stereotypes and biases. It also emphasizes the ability for each participant to be genuine with each other, with the therapist being genuine in a way that is clinically oriented and in the service of the client.
In most therapies, there are moments when tensions and feelings, at times very strong feelings, arise in the relationship between therapist and client. These feelings may include anger, frustration, and disappointment, and may not be exclusively experienced by the client, but by the therapist as well. A question raised at our roundtable discussion was what to do when difficulties arise in the relationship in multicultural therapy. From our relationship-based perspective, it becomes a matter of whether the difficulties can be approached from a working alliance, real relationship, or transference/countertransference perspective, or perhaps a combination of these perspectives. The alliance could explain the difficulties (e.g., feelings of boredom, frustration, or sense of being stuck) if the client or therapist or both have experienced difficulty in establishing trust with one another, or if one of them perceives them as not being “on the same page” and working on mutually agreed upon goals. Difficulties in the alliance may indicate that the tasks associated with meeting the goals of treatment need to be revised, or that the client has not received the proper level of support from the therapist in engaging in the tasks of therapy. Difficulties may also arise from the client experiencing a lack of sensitivity, including what have been termed “micro-aggressions,” from the therapist, which are subtle, perhaps unintended slights or failures to respond or validate meaningful experiences for the client (Sue, D. W. & Sue, D., 2013). Clients’ reactions would necessitate a therapist response that is affirming, responsive, and open to the client’s experience. Therefore it is important that therapists initially create a strong therapeutic alliance and safe environment for clients to feel comfortable enough to voice their feelings about the relationship with the therapist.
From a perspective of the real relationship, where genuineness and realistic perceptions are key to process and outcome, the participants may be experiencing difficulties being “who they are” with each other—thus the relationship lacks authenticity, the client may not feel safe, and the client or therapist may no longer be properly invested in the work. Gelso (2011) contrasts genuineness with being phony, which could happen when either the therapist or the client feels the need to put up appearances, for example out of fear of being judged or humiliated. When examined from a transference or countertransference lens, the difficulties in the relationship or the impediments in the therapeutic work may come from past experiences, feelings, or relationships that are unconsciously being reenacted in the hour. An example of transference in multicultural therapy may be a situation where the therapist is perceived or unconsciously experienced as an oppressor or as a hurtful person from the past; another example may be if the therapist is seen in the midst of a transference reaction as a representative of an unjust system or oppressive group. In these types of client reactions, possibly stemming from valid, reality-based past experiences, feelings such as anger, hurt, or fear may be seeking expression in the hour and will need to be empathically identified, examined, or worked through. An example of therapist countertransference in multicultural therapy may be when the therapist retreats or withdraws psychologically, even temporarily, out of discomfort or anxiety when the client brings up thoughts, feeling, or experiences with racism, bias, and/or oppression.
Participants at the roundtable also asked whether there is a “best” theoretical or technical approach to establishing a solid working relationship in multicultural therapy. For us, multiculturalism stimulates an appreciation for the individual in context and as formed and sustained through group memberships, beyond the individual and universal dimensions of being human (Leong, 1996). At the round table we noted that current research indicates that no one theoretical approach is superior or more effective to helping clients across a variety of settings and treatment issues. Outcome research has yielded similar therapeutic effects for a wide range of therapies when they are practiced competently by the therapist. In the context of multicultural therapy, our clinical experience tells us that the quality of the relationship remains the key component to process and outcome. Moreover, for some clients, an authentic, trusting, and therapeutic relationship may represent by itself the most important therapeutic process and outcome to be achieved from treatment. Therefore, at this point, there does not seem to be one best theoretical or technical approach to establishing a relationship in multicultural therapy. There are possibly many good approaches; however, therapists’ sensitivity to racism and oppression, awareness of the socialization process for all human beings, ability to maintain an accepting, respectful, and collaborative therapeutic stance, and empathy informed by racial identity and historical and social-political realities can supplement an otherwise competent approach to treatment in a way that promotes effective therapy with an array of minority clients (Smith, Rodriguez, & Bernal, 2011). Also of great importance is multicultural training, which consists of educational training experiences that focus on working with diverse client populations, developing self-awareness and overcoming personal biases, and receiving quality supervision from experienced and culturally-sensitive professionals (Fuertes, Spokane, & Holloway, 2013).
Finally, during our roundtable, we discussed the differences between treating clients who come from more collectivist cultures, as opposed to more individualistic cultures. From an applied clinical perspective, this issue presents a possible challenge to therapists, as many minority clients, particularly refugees and recent immigrants, have a deep commitment and sense of obligation to their families and communities. At the same time, these same clients may simultaneously present in therapy with concerns about personal growth, personal achievement, personal freedom, and self-efficacy. In some cases they may have needs in therapy to question, criticize, and work through familial or cultural beliefs and expectations that are being experienced as burdensome or that create some conflict. As an example, consider a first-generation Pakistani female college student who is nearing her graduation from college and has an outstanding job offer that would require her to move to another city. She expects her parents would reject this option, and this causes her great anxiety and stress. Therapeutic work in this type of scenario would include helping the client achieve a balance between her personal goals and her obligations to family—and research suggests that this work would be facilitated, in most therapies, by a solid therapy relationship.
We end by noting that much more theoretical and empirical work in needed in the areas of the therapy relationship and multicultural psychotherapy, and that this work is crucial given the demographic and cultural changes taking place in the U.S., changes that are inevitably reflected in psychotherapy practice.