Psychotherapy with Members of Diverse Populations
Effects of Therapist-Client Matching:
1. Research on therapist-client matching in terms of race, ethnicity, or culture has produced
inconclusive results. Sue et al. (1991) found that ethnic matching reduced premature
termination rates for Asian, Hispanic, and White Americans but not for African Americans
and that matching was associated with improved treatment outcomes for Hispanic American
clients only.
2. More recently, based on their meta-analysis of seven studies, Maramba and Nagayama Hall
(2002) concluded that ethnic matching has a small, but not significant, positive effect on
number of therapy sessions attended.
3. Some studies suggest that the preference of clients for ethnically similar therapists and the
effects of matching depend on certain individual factors such as the client’s ethnic identity,
level of acculturation, gender, and trust of Whites. For example, people with a strong
commitment to their culture are more likely to prefer an ethnically similar counselor. Also for
many members of culturally diverse groups, other factors – especially therapist education
and similarity in values and worldview – are more important than similarity in terms of race,
ethnicity, or culture (e.g., Pope-Davis et al., 2002).
Guidelines for Members of Specific Groups:
The research suggests that some generalizations can be made about the characteristics or
preferences of individuals belonging to particular groups. However, it is important not to
stereotype therapy clients on the basis of their race/ethnicity, sexual orientation, or other
characteristics.
1. African Americans: (Sue and Sue, 2003) – A therapist should consider…
a. The African American worldview emphasizes the interconnectedness of all things and,
as a result African Americans tend to emphasize group welfare over individual needs.
b. The family is often an extended kinship network that incudes both nuclear and
extended family members as well as individuals outside the biological family. For
many African Americans, the church is an important part of the extended family.
c. Roles within African American families are often flexible. Relationships between men
and women tend to be egalitarian and adults and children may adopt multiple roles.
d. Due to their history in the United States, African Americans may exhibit signs of
“healthy cultural paranoia.”
Systems that may be incorporated into treatment include the extended family and non-blood kin,
the church, and other community resources, and social service agencies. Some experts also
recommend using a time-limited, directive, goal-oriented, problem solving approach when
working with African American clients and fostering empowerment by promoting egalitarianism
in the therapeutic relationships (e.g., Aponte, 1994; Paniagua, 1994). Finally, when a therapist is
not African American, it is often useful to discuss the client’s reaction to having a therapist of a
different racial/ethnic background during the initial session.
1
2. American Indians and Alaskan Natives: (Sue and Sue 2003) – are likely to…
a. Exhibit a spiritual and holistic orientation to life that emphasizes harmony with nature
and regards illness as the result of disharmony.
b. Place a greater emphasis on the extended family and tribe than on the individual and
adhere to a consensual collateral form of social organization and decision-making.
c. Perceive time in terms of personal and seasonal rhythms, rather than in terms of the
clock or calendar and be more present-than future-oriented.
d. Exhibit a strong sense of cooperation and generosity.
e. Consider listening more important than talking.
Therapy guidelines include focusing on building trust, and credibility during initial sessions by
demonstrating familiarity with and respect for the client’s culture and admitting any lack of
knowledge; adopting a collaborative, problem-solving, client-centered approach that avoids
highly directive or confrontational techniques, and incorporating elders, medicine people, and
other traditional healers into the treatment process.
3. Asian Americans: Sue and Sue 2003) – include people of Chinese and Japanese
heritage, Pacific Islanders, and Southeast Asians. When working with an Asian American
client, it is important to be aware of his/her country of origin and acculturation status since
these factors will influence the client’s language and customs, social relationships, and attitudes
toward mental illness and psychotherapy. In general, Asian Americans…
a. Place greater emphasis on the group (family, community) than on the individual.
b. Adhere to a hierarchical family structure and traditional gender roles.
c. Emphasize harmony, interdependence, and mutual loyalty and obligation in
interpersonal relationships.
d. Value restraint of strong emotions that might otherwise disrupt peace and harmony
and/or bring shame to the family
In therapy, a directive, structured, goal-oriented, problem-solving approach that focuses on
alleviating specific symptoms is often preferred. Asian clients expect therapists to give concrete
advice and view the therapist as a knowledgeable expert and authority figure. Cognitivebehavioral, solution-focused, and other brief therapies are often effective but may need to be
modified so they focus more on the family than on an individual and take into account cultural
and social factors.
4. Hispanic/Latino Americans (Sue and Sue 2003) – include Mexican Americans, Puerto
Ricans, Cuban Americans, and people from Spain, Central and South America, and the
Caribbean. These individuals…
a. Emphasize family welfare over individual welfare and stress allegiance to family over
other concerns.
b. View interdependence as both healthy and necessary and highly value connectedness
and sharing.
c. Consider discussing intimate personal details with strangers (e.g., a therapist) as
highly unacceptable and believe that problems should be handled within the family or
other natural support system.
d. Adopt a concrete, tangible approach to life (rather than an abstract, ong0term
perspective).
2
e. Often attribute the control of life events to luck, supernatural forces, acts of God, or
other external factors.
When working with a Hispanic or Latino client, a therapist is usually best advised to be active
and directive and to adopt a multimodal approach that focuses on the client’s behavior, affect,
cognitions, interpersonal relationships, biological functioning, etc. Paniagua (1994) recommends
family therapy for Hispanic/Latino clients because “it reinforces their view of ‘familismo’ and the
extended family.
5. Sexual Minorities: There is evidence that lesbian, gay, bisexual, and transgender (LGBT)
individuals have higher rates of certain psychological problems. For example, as a group,
youth who identify as non-heterosexual are more likely than their heterosexual peers to
experience depression, anxiety, and substance use and to have a higher risk for suicidality
(e.g., Cochran & Maya, 2006); Russell, 2006)
a. In one study, Martin and Hetrick (1988) found that social and emotional isolation was
the primary presenting problem for a sample of gay and lesbian adolescents seeking
assistance at a social and educational agency for sexual minority youth.
b. According to Sue and Sue (2003), the impact of prejudice, discrimination, and
internalized homophobia can be effectively addressed in therapy by identifying and
correcting cognitive distortions, providing training in assertiveness and coping skills,
and activating social support systems.
Identity Development Models:
An important consideration when working with members of culturally diverse groups is the
individual’s racial/ethnic or sexual identity. The major models of identify development are:
1.
Racial/Cultural Identify Development Model (Atkinson, Morten, & Sue, 1993)
• Stage 1: Conformity. This stage is characterized by positive attitudes toward and
preference for dominant cultural values and depreciating attitudes toward one’s
own culture. A client in this stage is likely to prefer a therapist from the majority
group.
• Stage 2: Dissonance. The dissonance stage is marked by confusion and conflict
over the contradictory appreciating and depreciating attitudes that one has toward
the self and toward others of the same and different groups. People in this stage
are likely to prefer a therapist from a racial/cultural minority group and usually
perceive their personal problems as being related to racial/cultural identify issues.
• Stage 3: Resistance and Immersion. People in this stage actively reject the
dominant society and exhibit appreciating attitudes toward the self and toward
members of their own group. A person in this stage prefers a therapist from the
same racial/cultural group and is likely to perceive personal problems as the result
of oppression.
• Stage 4: Introspection. This stage is characterized by uncertainty about the rigidity
of beliefs help in Stage 3 and conflicts between loyalty and responsibility toward
one’s group and feelings of personal autonomy. People in this stage continue to
prefer therapists from their own group but are more open to the therapists who
share a similar worldview.
3
•
Stage 5: Integrative Awareness. At this stage, people experience a sense of selffulfillment with regard to their cultural identify and have a strong desire to
eliminate all forms of oppression. They also adopt a multicultural perspective and
objectively examine the values, beliefs, etc. of their own group and other groups
before accepting or rejecting them. In terms of therapist preference, clients in this
stage place greater emphasis on similarity in worldview, attitudes, and beliefs than
on ethnic, racial, or cultural similarity.
People may progress in a linear way through the five stages, or because of changes in
cross-ethnic/cultural interactions and relationships, may remain at one stage or move
forward or backward. In families, members may be at different stages, which can lead to
conflict.
2.
Black Racial (Nigrescence) Identity Development Model (Cross, 1971, 1991,
2001):
• Pre-Encounter: Race and racial identify have low salience during the preencounter stage. Individuals in the assimilation substage have adopted a
mainstream identify, while those in the anti-Black substage have accepted negative
beliefs about Blacks and, as a result, are likely to have low self-esteem. Individuals
in the pre-encounter stage usually prefer a white therapist.
• Encounter: Exposure to a single significant race-related event or series of events
leads to greater racial/cultural awareness and an interest in developing a Black
identity. In this stage, the individual is likely to prefer a therapist of the same race.
• Immersion-Emersion: Race and racial identify have high salience during this
stage. A person in the immersion substance idealizes Blacks and Black culture and
feels a great deal of rage toward Whites as well as guild and anxiety about his/her
own previous lack of awareness of race. During the emersion sub-stage, intense
motions subside, but the individual rejects all aspects of the White culture and
begins to internalize a Black identity. Cross refers to the attitudes associated with
these two substances as intense Black involvement and anti-White, respectively.
• Internalization: Race continues to have high salience, and individual in this stage
have adopted one of three identifies – pro-Black, non-racist (Afrocentric)
orientation, a bi-culturist orientation that integrates a Black identify with a White
or other salient cultural identity, or a multiculturalist orientation that integrates a
Black identity with two or more other salient cultural identities. Individuals in this
stage (especially those who have adopted an Afrocentric identify) may actively
work to eradicate racism and, in therapy, may exhibit healthy cultural paranoia.
3.
White Racial Identify Development Model (Helms, 1990, 1995): According to
Helms, racism is a central part of being White in America, and her model proposes that
identify development involves two phases: abandoning racism (statuses 1-3) and
developing a nonracist White identify (statuses 4-6). Each status is characterized by a
different information-processing strategy (IPS), which refers to the methods the
individual uses to reduce discomfort related to racial issues.
• Contact Status: The individual has little awareness of racism and his/her racial
identify and may exhibit unsophisticated behaviors that reflect racist attitudes and
4
•
•
•
•
•
4.
beliefs (e.g., may consistently base judgments of members of minority groups on
White society’s standards). The IPS for this status is obliviousness and denial.
Disintegration Status: Increasing awareness of race and racism leads to confusion
and emotional conflict. To reduce internal dissonance, the person may overidentify with members of minority groups, acts in paternalistic ways toward them,
or retreat into White society. The IPS for this status is suppression of information
and ambivalence.
Reintegration Status: The individual attempts to resolve the moral dilemmas
associated with the disintegration status by idealizing White society and
denigrating members of minority groups. He/she may blame minority group
members for their problems and view Whites as the victims of reverse
discrimination. The IPS for this status is selective perception and negative outgroup distortion.
Pseudo-Independence Status: A personally jarring event or series of events causes
the person to question his/her racist views and acknowledge the role that Whites
have had in perpetrating racism. The person is interested in understanding
racial/cultural differences but does so on an intellectual level. The IPS for this
status is selective perception and reshaping reality.
Immersion-Emersion Status: The individual explores what it means to be White,
confronts his/her own biases, and begins to understand the ways he/she benefits
from White privilege. This status is characterized by increased experiential and
affective understanding of racism and oppression. The IPS for this status is hypervigilence and reshaping.
Autonomy Status: The individual internalizes a nonracist White identify that
includes an appreciate of and respect for racial/cultural differences and
similarities. He/she actively seeks out interactions with members of diverse
groups. The IPS for this status is flexibility and complexity.
Homosexual (Gay/Lesbian) Identity Development Model (Troiden, 1988): This
model distinguishes between four stages:
• Stage 1: Sensitization/Feeling Different. During this stage, which is usually a
characteristic of middle childhood, the individual feels different from his/her
peers. For example, the individual may realize that his/her interests differ from
those of same-gender classmates.
• Stage 2: Self-Recognition/Identity Confusion. At the onset of puberty, the
individual realizes that he/she is attracted to people of the same sex and attributes
those feelings to homosexuality, which leads to turmoil and confusion.
• Stage 3: Identify Assumption. During this stage, the individual becomes more
certain of his/her homosexuality and may deal with this realization in a variety of
ways – e.g., by trying to “pass” as heterosexual, by aligning him/herself with the
homosexual community, or by acting in ways consistent with society’s stereotypes
about homosexuality.
• Stage 4: Commitment/Identify Integration. Individuals in this state have adopted a
homosexual way of life and publicly disclose their homosexuality.
5