Cultural humility and racial microaggressions in cross-racial clinical supervision: A moderated mediation model.

Cultural humility is important in supervision; however, studies have primarily sampled White supervisees. Racially and ethnically minoritized trainees experience microaggressions during their training, yet cross-racial supervision is less often studied. We examined a moderated mediation model to test whether the supervisory working alliance mediated the relationship between frequency of racial microaggressions and satisfaction with supervision, and whether the impact of racial microaggressions on the supervisee and supervisor cultural humility moderated the relationship between racial microaggression frequency and the supervisory working alliance. In a sample of supervisees of color (N = 102; majority cisgender women, 86.2%, and heterosexual, 59.8%; 35.3% Black/African American, 28.4% Asian/Pacific Islander, 18.6% Hispanic/Latine) receiving clinical supervision from White supervisors, we found that racial microaggression frequency was negatively associated with satisfaction with supervision, and this relationship was fully accounted for by the supervisory working alliance. Racial microaggressions in supervision were found to be detrimental to the supervisory working alliance, which was then related to lower satisfaction with supervision. Further, racial microaggression impact and cultural humility moderated the relationship between racial microaggression frequency and the supervisory working alliance; this relationship was strongest when racial microaggression impact was high and cultural humility was average or high. The social bond hypothesis suggests we are more likely to allow ourselves to be vulnerable when we assess cultural humility to be high. We posit that the observed moderation effect may be due to supervisees experiencing greater shock when experiencing racial microaggressions from supervisors whom they perceived to be culturally humble. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Sudden gains and deteriorations: Modeling the impact across outcomes with university counseling center clients.

OBJECTIVE: This study examines the longitudinal impact of sudden gains/deteriorations across the outcomes associated with the phase model. METHOD: In a sample of 16,657 clients who completed the Behavioral Health Measure-20, we identified sudden gains/deteriorations and employed multilevel piecewise analyses to assess their impact on subsequent treatment phases. RESULTS: We found that: (1) Following a sudden gain in the well-being outcome, the mean-level for the symptom outcome increased (meaning symptoms improved), and the rate of change decreased, (2) Following a sudden gain in the symptom outcome, the mean-level for the life functioning outcome increased, (3) Following a sudden deterioration in the well-being outcome, the mean-level and rate of change for the symptom outcome decreased, and (4) Following a sudden deterioration in the symptom outcome, the mean-level for the life functioning outcome decreased. CONCLUSIONS: These findings reveal that sudden gains/deteriorations function and occur at different rates across phases of change in psychotherapy.

The sum of competing parts: Religious and sexual identity disparities in therapist effectiveness.

The discussion of the influence of culture in psychotherapy is expanding to honor and incorporate the ways identities intersect within complex social systems. Some clients present for therapy with two or more identities that are in conflict, whereby the values or needs associated with different parts of the self are at odds. The resulting tension can be a significant driver of distress. This study sought to investigate therapist variability in facilitating change with clients depending on the interaction of their sexual orientation and the role of religion in their life (RR). We analyzed the depression scores of clients (n = 1,792) who received care at a university counseling center. After controlling for clients' pretherapy depression scores, the association between their sexual orientation and their posttherapy depression varied across therapists; however, the association between their RR and posttherapy depression did not. We also found that the association between the interaction of clients' sexual orientation and RR, and posttherapy depression varied across therapists. Therefore, some therapists had clients who experienced more or less change in their depression and that variability was predicted by the identity combinations clients endorsed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The myth of the safe space: Sexual orientation disparities in therapist effectiveness.

Psychotherapy has been shown to be effective on a broad level (e.g., Wampold & Imel, 2015); however, a growing body of literature has revealed that some therapists have outcome inequities within their caseloads. These inequities have been observed on the basis of social identities including race (see Imel et al., 2011, for example) and gender measured on the binary (Owen et al., 2009). However, despite the great need for further research on sexual minority populations in psychotherapy, this phenomenon has yet to be explored on the basis of sexual orientation (i.e., if a disparity exists within-therapist caseloads between queer-identified and heterosexual clients). The present study was comprised of a sample of 1,725 clients treated by 50 therapists at a university counseling center (17.7% of the sample endorsed a sexual minority status). Multilevel modeling was used to analyze data from the Behavioral Health Measure-20 (BHM-20; Kopta & Lowry, 2002). The results indicated that clients' sexual orientation status was not significantly associated with any of the BHM-20 subscales or with the Global Mental Health Scale (GMH). Of interest was that therapists varied in the extent to which their clients' symptoms and GMH improved and how that improvement varied by client sexual orientation status. Thus, attention must be paid not only to which therapists are more and less effective overall, but also to the specifics of which clients (and the social identities those clients hold) are improving while under their care. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

To conceal or not to conceal: Supervisee and client identity processes in clinical supervision.

Supervision is often conceived of as the "instructional strategy that most characterizes the preparation of mental health professionals" (Bernard & Goodyear, 2019; p. 2). Engaging in this process fully and authentically inevitably involves being vulnerable in front of and with one's supervisor in an effort to learn and grow. To more fully understand the supervisory relationship, researchers have focused on what supervisees do and do not share with their supervisors. This article sought to understand the extent to which supervisees engage in a process of concealment or nondisclosure about culture while in supervision. Cultural concealment (operationalized by Drinane, et al., 2018) was measured on 2 levels: one focused on if the supervisee concealed their own culture and one focused on if the supervisee concealed aspects of their clients' cultural identities. First, we found significant negative associations between each of these levels of cultural concealment and satisfaction with supervision and the supervisory working alliance. We then computed a residual score whereby supervisee cultural concealment about clients was predicted by supervisee cultural concealment about themselves. This residual variable was a significant predictor of satisfaction with supervision with supervision and with the supervisory working alliance, indicating that the relationship between these levels of concealment is important and related to the process of supervision. Implications and future directions will be discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The Alliance-Outcome Association in Couple Therapy: A Common Fate Model.

The working alliance has been shown to be a robust predictor of couple therapy outcomes. However, there are still questions regarding the best way to conceptualize and analyze the association between the alliance and outcomes in the couple therapy context. This study presents results from a relatively novel analytic approach for evaluating the alliance and therapy outcomes via the shared influence model (i.e., common fate statistical methodology) with 93 couples who had at least three sessions. Examining the alliance in couple therapy this way allows for nuance in conceptualizing the process of the alliance among partners and the therapist in couple therapy. Empirically, the question that remains is whether the shared experience of the alliance between partners is a stronger predictor of therapy outcome as compared to the unique individual experiences of the alliance. This approach has not yet been utilized to model the couple alliance-outcome association. Results revealed that the shared influence model demonstrated a significant association between the alliance and therapy outcome. Specifically, the couple-level alliance construct was adequately represented from the partners' alliance ratings with the therapist, and couples that report higher shared alliance experiences were also likely to have better therapy outcomes. These findings suggest that conceptualizing and analyzing the alliance at the couple level may be strongly advantageous. Implications for research and practice are provided.

Se ha demostrado que la alianza terapéutica es un predictor fiable de los resultados de la terapia de pareja. Sin embargo, aún quedan preguntas con respecto a la mejor manera de conceptualizar y analizar la asociación entre la alianza y los resultados en el contexto de la terapia de pareja. Este estudio presenta resultados de un enfoque analítico relativamente innovador para evaluar la alianza y los resultados de la terapia mediante el modelo de influencia compartida (p. ej.: metodología estadística del destino común) con 93 parejas que tuvieron al menos tres sesiones. Analizar la alianza en la terapia de pareja de esta manera permite matices a la hora de conceptualizar el proceso de la alianza entre los integrantes de la pareja y el terapeuta en la terapia de pareja. Empíricamente, la pregunta que queda pendiente es si la experiencia compartida de la alianza entre los integrantes de la pareja es un predictor más fiable de los resultados de la terapia en comparación con las experiencias individuales únicas de la alianza. Este enfoque aún no se ha utilizado para interpretar la asociación entre la alianza de la pareja y los resultados. Los resultados revelaron que el modelo de influencia compartida demostró una asociación significativa entre la alianza y los resultados de la terapia. Específicamente, el constructo de la alianza a nivel de la pareja se representó adecuadamente a partir de las valoraciones de la alianza de los integrantes de la pareja con el terapeuta, y las parejas que informan más experiencias de alianza compartida también fueron propensas a tener mejores resultados en la terapia. Estos datos sugieren que puede ser enormemente ventajoso conceptualizar y analizar la alianza a nivel de la pareja. Se explican las consecuencias para la investigación y la práctica.

Psychotherapy racial/ethnic disparities in treatment outcomes: The role of university racial/ethnic composition.

OBJECTIVE: Mental health disparities between racial/ethnic minorities (REM) and White individuals are well documented. These disparities extend into psychotherapy and have been observed among clients receiving care at university/college counseling centers. However, less is known about if campus RE composition affects outcomes from psychotherapy for REM and White clients. METHOD: This study examined psychotherapy outcomes from 16,011 clients who engaged in services at 33 university/college counseling centers. Each of these clients completed the Behavioral Health Measure as a of part routine practice. Campus RE composition was coded from publicly available data. RESULTS: The results demonstrated that White clients had better therapy outcomes than REM clients when they were at campuses where there were more White students. For universities 1 SD below the mean percentage of White students, the average difference in therapy outcomes for White and REM clients was Cohen's d = .21 (with White students experiencing more improvement); however, for universities 1 SD above the mean, the between group outcome disparity was greater (Cohen's d = .38). CONCLUSION: Therapists and higher education professionals should consider environmental impacts on counseling services. Implications for higher education, counseling centers, and mental health disparities are provided. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Are high-performing therapists both effective and consistent? A test of therapist expertise.

OBJECTIVE: Therapist effectiveness has primarily been defined as being the aggregate of the client therapy outcomes within a therapist's caseload. It may seem intuitive that the most skilled therapists are both effective (in the way defined above) and consistent in facilitating positive outcomes across their clients; however, this premise has not been fully tested. The present study sought to empirically examine this question in a large, multisite, geographically diverse sample. We first computed a consistency variable and an aggregate outcome variable for each therapist among a subset of each individual therapist's caseload (the first 30 clients per therapist within our data set). We then utilized this consistency score and aggregate outcome score to predict the therapy outcomes of their remaining clients. Clients' pretreatment severity scores were also included as a moderator of the association between therapist consistency, therapist aggregate outcome, and client outcomes. METHOD: The sample included 27,778 clients who were treated by 275 therapists. At the start of each session, clients completed the Behavioral Health Measure-20 as a measure of psychological functioning. RESULTS: Polynomial regression and response surface analysis indicated a discrepant effect, such that subsequent clients' outcomes were highest when therapists' aggregate outcome with their first 30 clients was high and the consistency in the outcomes of their first 30 clients was also high. This relationship was not moderated by clients' pretreatment severity. CONCLUSION: Therapists' expertise consists of both high performance and consistency. Therapists who achieved better outcomes consistently were top performers with their subsequent clients. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The detrimental effect of fragile groups: Examining the role of cultural comfort for group therapy members of color.

Scholars have underscored the importance of cultural processes within therapy groups, but there is a paucity of empirical research on this topic. Recently, the multicultural orientation framework was applied to group therapy to address this limitation and empirically test the role of cultural comfort, cultural humility, and cultural opportunities in a group context. Despite this advancement, a more nuanced understanding of the differential effects of cultural processes based on group members' race/ethnicity status is needed. Informed by theory and research on White fragility, this study sought to test the differential relationship between cultural comfort and cultural concealment, as well as cultural comfort and improvement, for 97 Racial-Ethnic Minority (REM) and 109 White members of 49 therapy groups. As hypothesized, REM status significantly moderated the association between cultural comfort and clients' cultural concealment and improvement, such that cultural comfort was negatively associated with cultural concealment and positively associated with improvement in group therapy for REM clients but not White clients. Results and implications are discussed within a fragility framework. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The Psychotherapy Outcome Problem: The Development of the Outcome Stability Index.

OBJECTIVE: Psychotherapy research commonly utilizes clients' last session score as an indicator of treatment outcome. We examined whether this last session score is consistent with what would be predicted based on clients' general trajectory in psychological functioning across sessions. We focused on the unstandardized residual variance at the last session, as this represents the degree to which the session score is divergent (or not) from what is predicted from the previous sessions (i.e., Outcome Stability Index; OSI). METHOD: The sample included 27,958 clients who attended on average 9.41 sessions. Each session, clients completed the Behavioral Health Measure-20 as a measure of psychological functioning. We converted the unstandardized residual variance for clients' last session score into a Cohen's d coefficient to aid in interpretation. RESULTS: The mean OSI was 0.07 (SD = 0.58), suggesting excellent stability in their last session therapy outcome scores. However, approximately 33% of clients demonstrated poor or extremely problematic stability in their last session therapy outcome scores. Clients who demonstrated poor stability were classified as demonstrating reliable deterioration. CONCLUSIONS: Researchers may want to consider reporting OSI to assist readers' understanding of the stability of therapy outcomes. Clinical or methodological significance of this article: Therapy outcome scores can vary from session to session, which can influence how we understand therapy outcomes that rely on last session scores. Studies examining therapy outcomes could report the Outcome Stability Index to better contextualize the results.

Construction and validation of the Multicultural Orientation Inventory-Group Version.

Given the continued racial/ethnic diversification of the United States, it is not uncommon for therapy groups to consist of members with diverse racial/ethnic backgrounds and various cultural identities. Scholars have underscored how this cultural diversity can directly impact many processes and outcomes of group-based interventions (Chen, Kakkad, & Balzano, 2008). However, there is presently a paucity of empirical research testing the relationship between cultural processes of therapy groups and members' outcomes. Moreover, no psychometrically sound measure of the cultural process that unfolds in group therapy currently exists. As such, this study sought to adapt the Multicultural Orientation Inventory to develop and validate the Multicultural Orientation Inventory-Group Version (MCO-G), a measure assessing the cultural humility, cultural comfort, and cultural missed opportunities in therapy groups. Data for this validation study consisted of 208 members of 49 therapy groups across 10 university counseling centers. Confirmatory factor analyses supported a 3-factor structure of the MCO-G Inventory, wherein the 3 factors corresponded with the underlying constructs of cultural humility, cultural comfort, and cultural missed opportunities. This study provides initial evidence for the estimated internal and convergent validity of the MCO-G, as measured by clients' perceptions of a higher-order group therapeutic factor and improvement in therapy. Results provide initial support for the psychometric properties of the MCO-G. Moreover, groups' cultural humility and cultural missed opportunities were related to members' improvement in therapy. Clinical implications and future research are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Cultural concealment and therapy outcomes.

Therapy is predicated on the need for clients to share intimate details about their lives, including their cultural values, attitudes, and beliefs. Previous studies have found that clients conceal certain aspects of their lives including, but not limited to their symptoms and their feelings about the therapy process. To date, there has not been an investigation focused on whether clients conceal aspects of their cultural identities, whether some therapists are more likely to have clients conceal aspects of their cultural identities, and if cultural concealment is associated with therapy outcomes. The present study attempted to do so utilizing the caseloads of 37 therapists who treated a total of 233 clients in a university counseling center setting. Client data were collected at the end of treatment utilizing the Patient's Estimate of Improvement (PEI; Hatcher & Barends, 1996), a measure that assesses client change on domains including general functioning, symptom related distress, intimate and social relationships, work or school, feelings about oneself, behavior, control of life, and tolerance for and ability to share painful feelings. Cultural concealment was assessed via 5 items regarding the amount and circumstances under which clients withheld cultural identity based information in therapy. Results indicated that within therapists' caseloads, client's ratings of cultural concealment were negatively associated with therapy outcomes. Additionally, therapists whose clients rated more cultural concealment on average had clients with worse therapy outcomes. Lastly, there was a significant contextual effect indicating that within and between therapist cultural concealment were statistically different from one another. (PsycINFO Database Record

Feedback informed treatment: An empirically supported case study of psychodynamic treatment.

The use of client feedback, via self-report measures of psychological functioning and working alliance, is an effective way to improve therapy outcomes. Despite this progress, there are many questions about the mechanisms of change for these systems. The current study employed a case study approach to examine the effectiveness of feedback informed treatment within a psychodynamic therapy. We examined the case based on therapy outcomes, alliance processes, and verbatim dialogue of in-session exchanges. We also conducted a semistructured interview with the therapist to understand how she used and interpreted the feedback within her psychodynamic approach. The results demonstrated positive therapy outcomes and that feedback assisted with alliance formation, specifically decision making about therapeutic tasks and managing negative countertransference. The therapist reported that the feedback enhanced her ability to work in the here and now and to identify relational patterns. Implications for theory and practice are discussed.

Multicultural competencies: What are we measuring?

The current study examined the validity of the client-rated version of the Cross-Cultural Counseling Inventory-Revised (CCCI-R). The first phase of this study involved a content validation of the CCCI-R by experts who had publications in the fields of multicultural competencies (MCCs) and psychotherapy research. Of the 20 items on the CCCI-R, 7 were rated as appropriate for client use. The second phase of this study utilized confirmatory factor analysis to examine construct validity by testing whether clients' perceptions of their therapists' MCCs (via the seven items validated by experts) were distinct from client-rated working alliance scores. Model fit statistics supported a theoretically based model in which MCCs were measured distinctly from working alliance, but where the two factors were related. Implications for theory and practice are discussed.

Psychotherapist effects in meta-analyses: How accurate are treatment effects?

Psychotherapists are known to vary in their effectiveness with their clients, in randomized clinical trials as well as naturally occurring treatment settings. The fact that therapists matter has 2 effects in psychotherapy studies. First, if therapists are not randomly assigned to modalities (which is rare) this may bias the estimation of the treatment effects, as the modalities may have therapists of differing skill. In addition, if the data are analyzed at the client level (which is virtually always the case) then the standard errors for the effect sizes will be biased due to a violation of the assumption of independence. Thus, the conclusions of many meta-analyses may not reflect true estimates of treatment differences. We reexamined 20 treatment effects selected from 17 meta-analyses. We focused on meta-analyses that found statistically significant differences between treatments for a variety of disorders by correcting the treatment effects according to the variability in outcomes known to be associated with psychotherapists. The results demonstrated that after adjusting the results based on most small estimates of therapist effects, ∼80% of the reported treatment effects would still be statistically significant. However, at larger estimates, only 20% of the treatment effects would still be statistically significant after controlling for therapist effects. Although some meta-analyses were consistent in their estimates for treatment differences, the degree of certainty in the results was considerably reduced after considering therapist effects. Practice implications for understanding treatment effects, namely, therapist effects, in meta-analyses and original studies are provided.