Making Cross-Racial Therapy Work: A Phenomenological Study of Clients' Experiences of Cross-Racial Therapy

Journal of Counseling Psychology
© 2009 American Psychological Association
2009, Vol. 56, No. 4, 521–536
0022-0167/09/$12.00
DOI: 10.1037/a0016905
Making Cross-Racial Therapy Work: A Phenomenological Study of
Clients’ Experiences of Cross-Racial Therapy
Doris F. Chang and Alexandra Berk
New School for Social Research
A phenomenological and consensual qualitative study of clients’ lived experiences of cross-racial therapy
was conducted to enhance the understanding of whether, how, and under what conditions race matters in
the therapy relationship. The sample consisted of 16 racial and/or ethnic minority clients who received
treatment from 16 White, European American therapists across a range of treatment settings. Participants
who reported a satisfying experience of cross-racial therapy (n
8) were examined in relation to
gender-matched controls and, in most cases, race/ethnicity-matched controls (n
8) who reported an
overall unsatisfying experience. Therapy satisfaction was assessed during the screening process and was
confirmed during the research interview. Therapy narratives were analyzed with consensual qualitative
research to identify client, therapist, and relational factors that distinguished satisfied participants from
unsatisfied participants. Findings reveal substantial differences at the level of individual characteristics
and relational processes, providing evidence of both universal (etic) as well as culture- or context-specific
(emic) aspects of healing relationships. Recommendations for facilitating positive alliance formation in
cross-racial therapy are provided, based on clients’ descriptions of facilitative conditions in the therapy
relationship.
Keywords: racial/ethnic matching, psychotherapy, therapeutic alliance, phenomenology
With the quickening pace of population growth among racial
guidelines highlight the importance of attending to racial and
and ethnic minorities in North America, interracial encounters in
ethnic issues, in particular, as they impact the therapy relationship
the therapy context are becoming increasingly common. Although
(Sue, Arredondo, & McDavis, 1992).
there are a number of visible markers of difference (e.g., gender,
Although there are numerous positive aspects of increasing
social class, age), race and ethnicity have been identified as espe-
interracial contact, such interactions are frequently experienced as
cially salient for both therapists and clients (Comas-Diaz & Jacob-
stressful by both majority and minority individuals and have been
sen, 1991). As a result, multicultural counseling competence
empirically linked to a number of negative cognitive, psycholog-
ical, physiological, and interpersonal outcomes (Clark, Anderson,
Clark, & Williams, 1999; Dovidio, Gaertner, Kawakami, & Hod-
son, 2002). As noted by Richeson and Shelton (2007), the specific
Doris F. Chang and Alexandra Berk, Department of Psychology, New
stressors associated with interracial contact vary across groups,
School for Social Research.
such that “White participants . . . are often concerned about ap-
This article is based in part on the data presented in this manuscript:
pearing prejudiced, whereas racial minorities are often concerned
“Racial/cultural identity and clients’ constructions of race in the therapy
about being the target of prejudice and/or about confirming neg-
relationship,” by D. F. Chang, C. Bitney, & K. Feldman, 2009, Unpub-
lished manuscript. Copyright 2009 by D. F. Chang, C. Bitney, & K.
ative group stereotypes” (p. 317).
Feldman. This research was supported in part by the Asian American
In the counseling context, researchers have described the par-
Center on Disparities Research (National Institute of Mental Health Grant
ticular discomfort that many White, European American counsel-
1P50MH073511-01A2).
ors experience when dealing with racial differences, compared
We express our appreciation to Carlos Baguer, Catherine Bitney, Jen
with other sociodemographic differences with their clients (Knox,
Chau, Injae Choi, Karen Cort, Kalli Feldman, Craig Fuller, Annie Goitein,
Burkard, Johnson, Suzuki, & Ponterotto, 2003; Utsey, Gernat, &
Chakira Haddock, Shihoko Hijioka, Elizabeth Lopez, Beth Manning, Poo-
Hammar, 2005). The present study, a qualitative exploration of
nam Melwani, N Jeri Mitchell, Adjoa Osei, Joel Sahadath, Ingi Soliman,
clients’ experiences of cross-racial therapy, focuses attention on
Jacqueline Springer, Jennifer Suero, Melissa Travostino, and Patricia Yoon
for their assistance with data collection, transcription, and data analysis.
the psychological and social significance of race, while acknowl-
We also thank Jonathan S. Kaplan for providing additional supervision and
edging the lack of consensus surrounding the construct in psycho-
training and for assisting with data collection. Finally, we extend our
logical research (Cokley, 2007; Helms, Jernigan, & Mascher,
appreciation to Derald Wing Sue and Charles Ridley for their comments on
2005). We share the view that racial categories are sociopolitical
a presentation of preliminary findings at the 2008 Annual Meeting of the
constructions rather than biological fact (Smedley & Smedley,
American Psychological Association (Boston, Massachusetts).
2005) and, therefore, cannot be studied as psychological constructs
Correspondence concerning this article should be addressed to Doris F.
in themselves (Helms et al., 2005). Nevertheless, one’s ascribed
Chang, Department of Psychology, New School for Social Research, 80
Fifth Avenue, 7th Floor, New York, NY 10011. E-mail: changd@
race does influence one’s socialization as a member of a dominant
newschool.edu
or oppressed group as well as the types of life experiences to which
521

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CHANG AND BERK
one is exposed (Helms, 2007). As such, the psychological signif-
cation that much may be unknown about how clients experience
icance of race is linked to its interpersonal significance, that is,
and negotiate interracial interactions in therapy. Indeed, clients and
how it shapes others’ perceptions, affective reactions, and behav-
therapists frequently differ in their views of how the therapy is
iors toward the racialized self and vice versa within a given social
progressing (Hannan et al., 2005). Although such misattunements
context. Along these lines, we choose to emphasize the term race
may become less frequent over time (Horvath & Bedi, 2002),
rather than the term ethnicity to reflect our interest in the former as
differences in therapist and client understandings of therapy events
a highly charged and frequently visible aspect of therapist-client
may lead to ruptures in the relationship, particularly in the begin-
differences that requires psychological processing and interper-
ning stage of treatment (Keenan, Tsang, Bogo, & George, 2005).
sonal negotiation. At the same time, we recognize that individuals’
The present study draws on recent trends in process and out-
internal representations and experiences of race may overlap with
come research that emphasize the role of client perceptions and
constructions of ethnicity and culture, blurring the already fuzzy
contributions to positive outcomes (Tallman & Bohart, 1999). To
boundaries between terms. In an effort to distinguish between
identify the conditions under which racial differences may affect
ascribed racial differences and their subjective psychological and
counseling satisfaction, we conducted a phenomenological/
interpersonal meanings, we apply the term race to denote the
consensual qualitative research study of racial/ethnic minority
former and the terms race and/or ethnicity or race and/or ethnicity
clients’ experiences of cross-racial therapy. Below, we provide a
and/or culture (REC) to denote the latter. Cross and Cross (2008)
brief review of the literature on the impact of racial differences on
likewise adopted the abbreviation REC to indicate that “the dis-
the therapy relationship as it informed the design of our study.
courses on racial, ethnic, and cultural identity overlap at the level
of the lived experience to the point that there is little reason to
The Therapeutic Relationship in Cross-Racial
associate each construct with a distinct identity constellation” (p.
Therapy Dyads
156). Terminology aside, as the literature on mismatches between
therapist and client has expanded, it is clear that one must move
Psychotherapy research involving racial and ethnic minority
beyond treating race as a grouping variable and unpack the various
clients has tended to focus on therapist characteristics, such as
subjective meanings that subtend racial and interracial experience.
racial attitudes (Ridley, 2005) and multicultural counseling com-
Despite studies implying the significance of therapist and client
petence (Fuertes et al., 2006), and therapist behaviors, such as
race in the therapeutic relationship (Coleman, Wampold, & Casali,
counseling style (Li & Kim, 2004), which are thought to influence
1995; Wintersteen, Mensinger, & Diamond, 2005), the literature
the therapeutic relationship. Although the field continues to strug-
on racial/ethnic matching does not suggest a strong relationship to
gle toward operationalizing multicultural counseling competence
clinical outcomes. On the one hand, several studies suggested that
and its component parts (Sue, Zane, Hall, & Berger, 2009), some
clients seeing a therapist of dissimilar race or ethnicity are more
research suggested that counselors’ multicultural counseling com-
likely to drop out of treatment and to attend a fewer number of
petence is critical for effectively working with clients of color,
sessions, compared with clients whose therapists share their racial/
accounting for a significant proportion of the variance in clients’
ethnic background (e.g., Sue, Fujino, Hu, Takeuchi, & Zane, 1991;
satisfaction beyond ratings of general therapist competence, attrac-
Wintersteen et al., 2005). However, meta-analytic studies indi-
tiveness, expertness, and trustworthiness (Constantine, 2002; Fu-
cated that the effect sizes associated with matching are small
ertes & Brobst, 2002). Conversely, perceptions of therapist cultural
(Maramba & Nagayama Hall, 2002; Shin et al., 2005), and match-
insensitivity and racial prejudice have been found to adversely
ing is not associated with symptom improvements (Erdur, Rude, &
affect minority clients’ experiences of therapy. For instance, recent
Baron, 2003; Sue et al., 1991). These findings confirm that match-
work applying the concept of racial microaggressions to the ther-
ing by itself is neither a necessary nor a sufficient condition for
apy context has demonstrated the ways in which counselors may
therapeutic effectiveness, nor is mismatching inherently problem-
unconsciously or unintentionally communicate denigrating mes-
atic. In fact, studies suggested that other individual and process
sages to minority clients. Examples include minimizing the im-
factors, such as racial or ethnic identity, cultural values, cultural
portance of racial– cultural issues to a client of color, pathologizing
mistrust, therapist cultural competence, and worldview match, are
cultural values or communication style, or conversely, normalizing
more proximally related to treatment outcomes and may moderate
potentially dysfunctional behaviors on the basis of an individual’s
the impact of racial differences (Helms & Cook, 1999; Zane et al.,
racial or cultural group (Sue, Bucceri, Lin, Nadal, & Torino,
2005).
2007). In a study of African American clients’ perceptions of their
Although this literature has been helpful in suggesting that there
White counselors, Constantine (2007) found that these expressions
are numerous intersubjective meanings and processes attached to
of more covert and frequently subconscious racist attitudes were
race in the context of counseling, the bulk of this work has grown
predictive of a weaker therapeutic alliance, lower ratings of gen-
out of investigators’ a priori assumptions about the significance
eral and multicultural counseling competence, and lower levels of
and meaning of race in individuals’ lives. Few studies have ex-
counseling satisfaction.
amined clients’ subjective experiences and perceptions regarding
Compared with therapist factors, studies of client factors and
the impact of racial difference on the therapy relationship. This is
their relationship to multicultural counseling process and outcome
particularly problematic, given that research indicates that it is the
are relatively rare. Although analogue studies of cross-cultural
client’s evaluation of the therapy relationship, not the counselor’s
counseling scenarios suggested the importance of client factors
view, which is most strongly associated with therapy outcome
such as racial identity and cultural values in predicting help-
(Horvath & Bedi, 2002). That research has shown that therapists
seeking preferences and counseling process (e.g., Atkinson &
are not fully aware of client reactions, particularly negative reac-
Lowe, 1995; Kim, Ng, & Ahn, 2005), few studies have examined
tions (Hill, Thompson, Cogar, & Denman, 1993) is further indi-
how clients’ attitudes, perceptions, and experiences relate to ther-

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CLIENTS’ EXPERIENCES OF CROSS-RACIAL THERAPY
523
apy process and outcome in actual, multicultural counseling rela-
tors also directed individuals early on in the interview to explicitly
tionships. The result is a knowledge base that is somewhat con-
consider such issues as “cultural differences and similarities” with
strained by investigators’ understandings of the factors that may
their therapist and “cultural concerns brought up in counseling.”
affect minorities’ experiences of therapy.
These instructions provided a conceptually focused but restrictive
A recent study by Sanders Thompson and Alexander (2006)
lens through which clients were asked to evaluate their experience
illustrated the limitations of relying on investigator-developed
of counseling. Although clients’ view of cultural competency was
measures of therapy process, even in the context of investigating
the focus of the study, the interview format may have biased
actual therapy encounters. The authors examined 44 African
clients toward emphasizing cultural issues in the therapy rather
American clients’ perceptions and experiences following random
than allowing them to describe whatever elements were salient in
assignment to either interpersonal or problem-solving therapy pro-
their own experience.
vided by either a European American or African American thera-
pist. Clients assigned to European American therapists were also
The Present Study
randomly assigned to one of two conditions regarding how racial
differences would be handled during the first session. Results
This study highlights the client’s perspective to enhance our
indicated that clients’ understanding and acceptance of the treat-
understanding of whether, how, and under what conditions race
ment approach and perceptions of therapeutic benefit was higher
matters in the therapy relationship. Our goal was to identify the
when the client was assigned to an African American therapist.
therapeutic and extratherapeutic elements that distinguished client
Contrary to expectation, European American therapists’ discus-
accounts of satisfying and unsatisfying experiences of cross-racial
sions of race in the initial session had no effect on therapy ratings.
therapy. Findings are used to clarify how REC differences influ-
The authors concluded, “It is conceivable that race, because of its
ence the therapeutic relationship and the etic and emic conditions
influence as a social category, affected how clients and therapists
deemed necessary for positive alliance formation.
interacted in therapy and the subsequent ratings of understanding
and acceptance of therapeutic goals and interventions” (Sanders
Method
Thompson and Alexander, 2006, p. 107). However, in the absence
of qualitative information about participants’ experiences of ther-
The qualitative approach to the study was informed by phenom-
apy, the authors were unable to ascertain the ways in which race
enology and consensual qualitative research (CQR; Hill, Thomp-
may or may not have played a role in clients’ final assessments.
son, & Williams, 1997). Phenomenology was selected as an
Moreover, they were unable to explain why European American
orienting framework in an effort to obtain a window into
therapists’ discussions of race had no effect on participants’ ther-
clients’ experiences of cross-racial therapy relationships, dis-
apy ratings.
tinct from preconceived notions regarding the social signifi-
In recent years, qualitative approaches have gained popularity as
cance of race and assumptions regarding how racial differences
a method for capturing the subjectivity inherent in assessing ther-
would be constructed and enacted in the therapeutic relation-
apy according to individuals’ working models of successful coun-
ship. Consistent with traditional phenomenological approaches
seling relationships (Levitt, Butler, & Hill, 2006). For example,
(Giorgi, 1997), we consciously sought to bracket previous disci-
Bedi (2006) interviewed 40 clients about the specific behaviors
plinary theories and assumptions regarding the importance and
considered helpful in the development of the therapeutic alliance.
impact of racial difference in cross-racial therapy dyads (Wertz,
In general however, the use of racially homogeneous client sam-
2005), though we acknowledge that they may have inadvertently
ples and the absence of data regarding therapist race within this
influenced the research process (see Author Biases below).
literature make it difficult to evaluate the extent to which findings
Whereas phenomenology informed our approach to data collec-
may generalize to cross-racial or cross-cultural counseling situa-
tion, CQR was adopted as our data analytic strategy. CQR pro-
tions.
vides a systematic method for assessing the representativeness of
In our review of the literature, we identified only one study of
key themes between those, which was useful for comparing results
minority clients’ subjective experiences of cross-racial or cross-
between those who had a satisfying, versus unsatisfying, experi-
cultural counseling. Pope-Davis and colleagues (2002) investi-
ence of cross-racial therapy.
gated clients’ conceptualizations of multicultural competency, us-
ing grounded theory. Ten students who had been in counseling
Sample and Recruitment Procedures
with a counselor who was “culturally different than themselves”
(Pope-Davis et al., 2002, p. 361) were interviewed about their
A stratified, matched pairs design was used to isolate the factors
counseling experience, focusing on how cultural issues affected
that predicted racial/ethnic minorities’ satisfaction with cross-
the working relationship and how cultural concerns were ad-
racial therapy. Satisfied participants were examined in relation to
dressed. The resulting theoretical framework provides a rich de-
gender-matched (and in most cases, race/ethnicity-matched) con-
scription of how clients actively conceptualized cultural compe-
trols who reported an overall unsatisfying experience. A diverse
tence and managed cultural differences in the counseling
sample of 16 participants (8 women, 8 men) was selected from a
relationship.
larger pool of 33 to create the matched pairs (see Table 1).
One important consideration, however, is the transferability of
Satisfaction ratings were dichotomously coded as either generally
their model, given the unique characteristics of the sample: pre-
satisfied or generally unsatisfied on the basis of participants’
dominantly young women engaged in university studies, with all
self-designation during the screening and research interviews.
but 1 reporting that cultural issues were moderately to very im-
Participants were recruited across New York City via multilin-
portant in their sessions (Pope-Davis et al., 2002). The investiga-
gual advertisements (in English, Chinese, Japanese, Korean, and

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CHANG AND BERK
Table 1
Participant Characteristics Stratified by Race/Ethnicity, Gender, and Treatment Satisfaction
Race and ethnicity
Gender
Satisfaction
Therapist race and ethnicity
Asian (Japanese)
Female
Satisfied
White
Asian (Chinese)
Female
Unsatisfied
White (German)
Asian (Chinese American)
Male
Unsatisfied
White (Russian)
Black (Black, born in Africa)
Female
Unsatisfied
White
Black (Nubian)
Female
Unsatisfied
White (Greek)
Black (African American)
Female
Satisfied
White
Black (African American)
Male
Unsatisfied
White (Jewish)
Black (African American)
Male
Satisfied
White (Greek)
Black (African American)
Male
Satisfied
White
Latino (Puerto Rican)
Female
Satisfied
White (Ukrainian)
Latino (Basque/Spanish/American)
Female
Satisfied
White (American, British)
Latino (Puerto Rican and Black Portuguese)
Male
Unsatisfied
White (Yugoslavian)
Latino (Mixed Black and Hispanic)
Male
Unsatisfied
White
Latino (Puerto Rican)
Male
Satisfied
White (Jewish)
Multiracial (Chinese and White)
Female
Unsatisfied
White
Multiracial (White Latino and Jewish)
Male
Satisfied
White (Jewish)
Note.
Client and therapist ethnicity, where indicated in parentheses, is provided in clients’ own words.
Spanish) posted on electronic and community bulletin boards and
The majority of participants (9) saw therapists in a private
local newspapers. Initial screenings were conducted by phone or
practice setting, although 7 were treated in a clinic or hospital.
e-mail. Eligibility criteria included a self-reported racial mismatch
There were no marked differences between clients who were
and treatment termination within the prior 12 months. Exclusion
satisfied and those who were dissatisfied with treatment with
criteria included a positive screen for psychotic symptoms or other
regard to age, treatment setting, duration of treatment, or present-
acute symptoms that would compromise their ability to provide
ing problem. The only characteristic that varied between groups
informed consent. Individuals who reported current involvement in
was educational level: Everyone in the unsatisfied group had
psychotherapy were also excluded from participation.
attended at least some college, whereas 3 of the participants in the
The broad recruitment effort yielded a demographically diverse
satisfied group had graduated from high school only.
sample of participants, which is reflected in the demographic
diversity of the 16 participants analyzed for this study. For this
Procedures
sample, ages ranged from 19 years to 50 years, with a mean of 33.5
(SD
8.8). Highest educational level was mixed, with 5 partici-
Interviewers were matched with participants on race/ethnicity,
pants who possessed advanced degrees, 2 who possessed an un-
gender, and language preference, although all 16 of the interviews
dergraduate degree, 6 who completed some college, and 3 who
presented here were conducted in English. There were 11 inter-
completed high school only. Five (32%) participants were born
viewers in our diverse pool of interview staff, all of whom con-
outside of the United States. Sexual orientation was not systemat-
ducted at least one interview. Multiracial participants were invited
ically assessed across the entire sample, although 6 (38%) partic-
to specify the interviewer race/ethnicity with which they felt most
ipants self-identified as lesbian, gay, transgender, bisexual, or
comfortable, as the possibility of assigning an interviewer on the
queer in the interview. All participants saw non-Hispanic White
basis of an exact racial/ethnic match was not possible. The inter-
therapists, and 12 of the 16 therapists seen were female. Length of
viewers consisted primarily of master’s and doctoral level students
treatment ranged from 6 weeks to 6 years. Seven participants
in counseling or clinical psychology. All interviewers received 6 hr
remained in therapy for 1 year or more, 7 remained in therapy for
of training that included discussion of articles on phenomenology,
6 months to a year, and 2 were treated for less than 6 months.
interviewing, and role plays of the interview protocol. Regular
The most common presenting problems (not mutually exclu-
supervision and feedback based on reviews of audiotapes of the
sive) were “loneliness/isolating myself from other people” (9),
interviews were provided by Doris F. Chang.
“mood swings or depression” (9), “career/work-related stress” (9),
The semistructured face-to-face interview lasted between 1 hr
“family conflicts” (8), and “feeling anxious for either known or
and 3 hrs. All interviews were conducted in lab offices on campus.
unknown reasons” (5). Seven participants (44%) discussed their
Before the interview began, informed consent was obtained and
presenting problems in the context of racial or cultural issues. For
participants were asked to provide basic demographic information
example, two of the Asian clients described feeling resentment
and to complete a checklist of problems that prompted them to
toward their families because they believed that childhood traumas
seek therapy when they did. Consistent with phenomenological
they had suffered were exacerbated by cultural norms around
approaches (Giorgi, 1997), the interview began with a “grand tour”
gender and family roles. Several participants perceived discrimi-
question in which participants were invited to tell the story of their
nation from superiors and peers in school and in the workplace,
therapy without explicitly directing them to discuss the implica-
which precipitated their distress and anxiety. Two immigrant cli-
tions of racial difference: “Please describe for me your experience
ents also reported varying degrees of acculturative stress and
of therapy, starting from the very beginning and taking me through
experiences of prejudice and discrimination.
that experience until the very end.” This open-ended question

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525
elicited a naturally unfolding description of participants’ experi-
Only at this point in the interview did we explicitly introduce
ence and allowed us to observe the salience of racial difference in
race into the discussion through a series of questions regarding
their initial constructions of the therapy story. To control for
participants’ racial, ethnic, and cultural identity attitudes and per-
individual differences in storytelling style and depth and breadth of
ceptions regarding the significance and the effect that racial dif-
their subjective accounts, we followed the initial grand tour ques-
ferences had on their therapy experience. Questions assessing the
tion with a semistructured interview that explored key time points
effects of race on the therapy relationship explored both the
in the chronology of the relationship (e.g., initial session, early
perceived advantages and the perceived disadvantages of mis-
phase, termination phase), perceptions of therapist characteristics,
matching. Lastly, clients were asked to draw on their own expe-
therapeutic relationship, and specific behaviors and interventions
riences to provide recommendations for therapists working with
considered to be helpful or unhelpful. The list of standard ques-
racially different clients. At the end of the interview, participants
tions asked of each participant is presented in Table 2.
were paid $30 for their participation and asked whether they would
Table 2
List of Standard Interview Questions
Item number
Item
1.
“Grand tour” question: Please describe for me your experience of therapy, starting from the very beginning and taking
me through that experience until the very end.
2.
Sometimes prior to seeing a therapist, people identify qualities that they want the therapist to have. What qualities did
you identify as being important before you went to your first appointment?
3.
Where did you go for treatment? What was it like?
4.
How did you get hooked up with your particular therapist?
5.
Now, I’d like you to think back to your very first session with your therapist. What do you remember about that first
meeting?
6.
What was your first impression of your therapist? Did you feel a connection with him/her?
7.
At the end of that session, did you want to come back? Why or why not?
8.
Tell me a little about your therapist.
9.
How much did you feel like you had in common? In what ways did you feel like you were different?
10.
How was it working with him/her? What kind of relationship did you have?
11.
How satisfied were you with how the therapy went? How helpful was it?
12.
What were specific things that the therapist did that were HELPFUL?
13.
What are specific things that the therapist did that were NOT HELPFUL?
14.
How did your therapy end?
15.
Some people consider themselves to be Black or African American, Asian, Chinese American, Latino, Mexican
American, White, American, Italian American, etc. How do you identify yourself?
16.
How much do you identify with (use client’s own words) culture versus (mainstream) White/European American culture?
For some people it is more important for them to hold on to cultural traditions and values, for others it is more
important to be a part of mainstream American culture, for some both are important, and for others, neither is as
important as some other aspect of their identity (i.e., religious, gender, etc.). What about for you? In your daily life,
how does that play out?
17.
Some people think that things such as race, ethnicity, and culture—these things we’ve been talking about—exert a
significant impact on the therapy relationship, while other people think that these factors are not very important. What
do you think?
18.
Reflecting on your experience in therapy, how important were racial differences?
19.
Thinking back on your experience in therapy, did the fact that you were from different backgrounds affect what you felt
comfortable sharing with him/her?
20.
Was there ever a time when you felt like your therapist just couldn’t understand you because of your racial or cultural
differences? Can you tell me what happened? How satisfied were you with how the misunderstanding was resolved?
21.
Thinking back to that first therapy session, did your therapist bring up the fact that you were from different racial, ethnic,
or cultural backgrounds? What was that like? IF YES: Was this an issue that came up again? IF NO: Did either of you
at any time talk about it directly?
22.
In general, how sensitive would you say your therapist was to issues related to race, ethnicity, and culture? What did
he/she do or say to make you feel that way?
23.
Looking back on your whole experience of therapy, how do you think it would have been different to be in therapy with
an (insert client’s racial/ethnic/or cultural identity in their own words) therapist? How important is it to you that your
therapist shares your background?
24.
As someone who has experienced this situation first hand, what kinds of suggestions do you have for therapists who are
working with people of different racial/cultural backgrounds?
25.
Do you think in general, that it would be helpful for therapists to talk about racial/cultural differences with their clients?

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CHANG AND BERK
be willing to be contacted 1 week later for a brief follow-up
demic interests in race, culture, and mental health have raised her
conversation “to see if you have any additional thoughts you’d like
awareness of the unintentional racism that even well-meaning
to share.” Interest in participating in a member-checking meeting
White service providers can exhibit toward minorities. She ex-
at the conclusion of the study was also assessed at this time.
pected that White therapists would not display overtly racist be-
Thirteen of the 16 participants consented to be contacted 1 week
havior toward their minority clients; however, they may inadver-
later to process their reactions to the interview and to clarify any
tently marginalize them by endorsing stereotypes or trying too
responses that were unclear. However, 8 of the 13 were unable to
hard to minimize the differences between them.
be reached despite repeated attempts. Following each contact,
Although we worked to bracket and examine our biases during
interviewers completed field notes which included behavioral ob-
all phases the study, we acknowledge that our expectations may
servations, salient themes, and process notes. Each interview was
have unconsciously influenced our understanding and interpreta-
digitally audiotaped and transcribed. Identifying information was
tion of the data presented here. Coding of the data proceeded in
removed and identification numbers were substituted for partici-
four stages.
pant names. For confidentiality purposes, all participant names
referenced below are pseudonyms.
Domain Coding
Analysis
The domain coding process originated with a set of domains
designated as a start list (Miles & Huberman, 1994) to aid in the
Interview data were analyzed with CQR (Hill et al., 1997). CQR
efficient development of a codebook. The initial set of domains,
emphasizes consensus building across multiple researchers as a
compiled from a review of the literature and the interview proto-
crucial component of the research process. To enhance the validity
col, was later refined through an iterative process consisting of
of our interpretations and to minimize groupthink, we convened a
open coding one transcript at a time and expanding, eliminating, or
diverse coding team of five judges plus an additional one to two
combining domains as required to fit the data (Hill et al., 1997).
rotating judges who participated in coding groups composed of
The codebook was finalized after coding five participants, as
two to three judges each. All judges were graduate students in
subsequent participants fit the emergent structure well. Teams of at
psychology, and four judges also served as interviewers. The self-
least two members independently coded each transcript, discussed
described identities of the judges were as follows: “White Latina,”
their results until consensus was obtained, and then submitted their
“gay White male,” “Hispanic female,” “mixed Vietnamese-Caucasian
consensus version of the results to the auditor. After final consen-
queer female,” “Japanese female,” “Korean American female,”
sus was achieved, the qualitative analysis software Atlas.ti (Muhr,
“adopted Korean female,” “mixed-race woman of Asian, White, and
2004) was used to organize the interview text into these central
Jewish descent,” “Hispanic female,” “African,” and “Jewish Ameri-
domains.
can woman.” The principal investigator, a Chinese American
woman, served as the primary auditor. As recommended by Hill et
Writing Core Ideas
al. (1997), before initiating the coding process, each judge re-
corded their expectations about the study based on their experi-
In the second stage of analysis, core ideas or a descriptive
ences and beliefs regarding the subject matter. The essays were
summary of key themes were written for all of the text captured
discussed as a group to facilitate communication and to reduce
within each domain for each individual participant and argued to
hidden biases pertaining to race, ethnicity, culture, and the therapy
consensus. The auditor reviewed the core ideas for each domain
relationship.
and provided feedback, and the original coding teams developed a
final consensus version for each participant.
Author Biases
Cross-Analysis
Doris F. Chang is a licensed clinical psychologist and an assis-
tant professor of clinical psychology. A second generation Chinese
In the final stage, core ideas for each domain were analyzed
American woman, she grew up in a predominantly White neigh-
across cases. Coding teams brainstormed how these core ideas
borhood in Texas that encouraged assimilation. Since leaving
converged into categories, adding an explicit interpretive layer to
Texas in 1994, she has lived and worked in a number of multi-
the thematic description that had preceded this stage (Hill et al.,
cultural environments, including cities in China and Taiwan, and
1997). The cross analysis was reviewed by the auditor, with
now considers herself to be bicultural. Given her own comfort
comments discussed by the team, to arrive at a final consensus
navigating culturally and racially diverse social environments as
version of the results. The number of participants that fit within
well as her therapeutic work with clients of diverse backgrounds,
each emerging category was tabulated as a means of describing the
she expected that the effects of race on the therapeutic relationship
representativeness of these categories across our two comparison
would vary according to clients’ own racial/cultural attitudes and
groups (satisfied versus unsatisfied). Following Hill et al. (1997),
communication skills as well as the therapist’s own comfort ad-
categories were labeled general if they applied to all eight cases
dressing racial differences. Alexandra Berk is a doctoral candidate
within a group, typical if they applied to at least half but not all of
in cognitive, social, and developmental psychology. In this study,
the participants (4 –7), and variant if they applied to less than half
she served as judge and project manager. Descended from Eastern
but at least 2 participants. Narratives of the satisfied and unsatis-
European Jews, she always maintained an interest in the psychol-
fied groups were systematically compared; only those categories
ogy of oppression and prejudice. Although she grew up in a
that differed in frequency class (e.g., typical versus variant) are
predominantly White suburb of Boston, her experiences and aca-
reported below.

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CLIENTS’ EXPERIENCES OF CROSS-RACIAL THERAPY
527
Validity Checks
Clients’ polarized descriptions of their experiences of therapy
support their self-classification into the two groups (satisfied and
The cross-analysis was initially conducted with 12 participants
unsatisfied). Emergent categories suggest convergence with theo-
to arrive at the final categories and their frequencies across groups.
retical descriptions of the working alliance, with clients basing
To assess whether theoretical saturation had been achieved
their overall evaluations of the therapy on the quality of the bond
(Strauss, 1987), we then incorporated an additional four partici-
between parties and their ability to work collaboratively to ad-
pants in the cross-analysis and confirmed that our final list of
dress the client’s treatment goals and expectations (Gelso &
categories could account for all of the data collected. The reanal-
Mohr, 2001). Thematic categories that differed in frequency
ysis also confirmed the original pattern of results, providing evi-
between the satisfied groups and the unsatisfied groups were
dence of redundancy of data, that is, evidence that the results were
organized into therapist factors, client factors, and relationship
stable and unlikely to change, even with the inclusion of additional
factors (see Table 3).
participants (Lincoln & Guba, 1985). Finally, the trustworthiness
or credibility of the results was assessed via member checking
Therapist Factors
(Lincoln & Guba, 1985). Consenting participants were invited to a
presentation and discussion of the study findings. Five participants
Differences in how satisfied and unsatisfied participants de-
attended the meeting and provided feedback that supported our
scribed their therapists were organized into two major areas:
emerging model. Individuals who were unable to attend were sent
therapist techniques and therapist personality characteristics. Note
a copy of the results and were invited to provide feedback by
that these categories emerged spontaneously in participants’ nar-
e-mail, although none did.
rative descriptions or in response to general probes about helpful
and unhelpful aspects of the therapy.
Results
Therapy Techniques
Description of Comparison Groups
Active versus passive style.
Compared with satisfied clients,
To clarify the meaning of clients’ global satisfaction ratings,
more than twice as many unsatisfied clients described their ther-
summative statements regarding their therapy experiences were
apists as passive or as not proactive enough (2 vs. 5). Specific
analyzed. Participants who described themselves as predominantly
complaints included the lack of feedback, progress reports, or deep
satisfied with therapy frequently reported that (a) their expecta-
questioning regarding the client’s experience. Conversely, indica-
tions and goals for the therapy were met (general), (b) they felt
tions that the therapist had an active or directive style were more
emotionally attached or connected to their therapist (typical), (c)
frequent in satisfied clients. Active style was conceptualized as
they felt satisfied with their termination experience (typical), and
composed of three subcategories, all of which were more common
(d) they were interested in maintaining contact with their therapist
in satisfied participants: (a) offering concrete advice, suggestions,
and/or resuming treatment at a later date (typical). For example,
and skill development, (b) asking thought-provoking questions and
Ane, a Latina participant who developed a close attachment to her
challenging the client’s thinking, and (c) providing psycho-
Anglo male therapist, summed up her final session as follows:
education. Overall, strategies such as providing direct answers and
offering concrete tips, advice, and mentoring were valued by two
It was important to me to see especially by the end of the therapy that
thirds of the clients.
he was very moved . . . . I did feel that there was all this respect and
Cultural competence.
Although participants did not explicitly
connection between us, and that is very meaningful to me because,
use the term cultural competence, a number specifically addressed
coming from a Latin culture, the emotional connection is the greatest,
their therapists’ capacity to work with racially or culturally differ-
most important thing.
ent clients. Half the total sample (8 of 16) criticized their therapists
for (a) providing interventions that were too textbook and not
In contrast, clients who described themselves as predominantly
tailored to the client’s specific life contexts and history and
unsatisfied tended to report that (a) they felt misunderstood or
(b) their lack of sufficient group-specific knowledge and experi-
disconnected from the therapist (general), (b) the therapy was not
ence. The majority of individuals from the unsatisfied group la-
beneficial or was “a waste of time” (typical), (c) the therapist was
mented their therapists’ lack of group-specific skills and knowl-
unable to fulfill their needs or expectations (typical), (d) the
edge, compared with a minority of the satisfied individuals.
therapist did not seem engaged or invested in the relationship
Culture-specific knowledge mentioned by participants as conspic-
(typical), and (e) the relationship degenerated over time (typical).
uously absent from their therapists’ knowledge base included
For example, Wei, an Asian client who saw a White Russian
issues related to being a sexual minority, racism and discrimina-
therapist described feeling as though the therapist was pushing him
tion, oppression related to multiple minority statuses, stigma re-
toward pharmacologic treatments for his depression rather than
lated to psychological problems and help-seeking, racial/cultural
engaging him in a therapeutic interaction. He summed up his
and multiracial and/or multicultural identity development, commu-
disappointment as follows:
nication style differences, and family cultural dynamics. For ex-
ample, Regina, a mixed-race (Asian/White) participant felt that her
It really didn’t feel like she was trying to serve me or help me. It was
that I was there to serve her so that she can write out something to the
therapist had “this kind of book-learned . . . image of some kind of
insurance company and get money from it. If you’re a patient and you
immigrant family, instead of . . . an emotional understanding of
come in wanting to engage and it doesn’t happen . . . you are just left
what it’s like to be, like, Asian in [specific small city, in the
kind of high and dry.
intermountain West].” Joel, a Black gay man, initially had high

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528
CHANG AND BERK
Table 3
Therapist, Client, and Relationship Factors That Distinguished Satisfied Participants From Unsatisfied Participants in
Cross-Racial Therapy
Category
Description
Satisfied
Unsatisfied
Therapist factors
Techniques
Active vs. passive stylea
Therapist adopted an active role in the therapy.
Typical
Variant
Therapist adopted a passive role in the therapy.
Variant
Typical
Cultural competence
Therapist’s interventions seen as too textbook and not tailored to client’s specific
Typical
life contexts/personal history.
Therapist’s knowledge about their community was perceived as superficial or
Variant
stereotypical.
Therapist was viewed as dismissing or minimizing of patient’s experiences of
Variant
oppression or exclusion due to minority status.
Therapist revealed a lack of awareness of the impact of their stereotypes or biases
Typical
about the patient’s racial/ethnic/cultural group on the client.
Self-disclosure
Therapist disclosed personal information to the client.
Typical
Variant
Professionalism/ethics
Therapist seen as unprofessional or engaging in ethically questionable practices.
Variant
Typical
Personal characteristics
Attentive vs. disengaged
Therapist was viewed as caring, sensitive, and attentive.
Typical
Therapist was not sufficiently attentive or engaged.
Variant
Typical
Accepting vs. critical
Therapist was viewed as validating and nonjudgmental.
Variant
Therapist seen as too critical or dismissive of client’s concerns.
Variant
Client factors
Perceptions of the salience of
Client emphasized therapeutic skills and the nature of the therapeutic task as
General
racial differencea
being more important than racial/ethnic differences.
Client perceived that racial/ethnic differences were irrelevant to the client’s
Typical
presenting problem and therapy goals.
Client perceived significant benefits of working with a racially different therapist.
Typical
History of intraracial/ethnic
Client described experiences of alienation from members of his or her own racial/
Variant
oppressiona
ethnic group.
Relationship factors
Client’s efforts to bridge
differencesa
Compartmentalization of race
Client acknowledged the influence of race/ethnicity in his or her life but
Typical
minimized its effect on the therapy relationship.
Identification with the therapist
Client emphasized shared aspects of identity with the therapist.
Typical
Therapist’s efforts to bridge
Client felt that therapist was culturally responsive and able to work through
differencesa
misunderstandings due to racial/ethnic/cultural differences.
Typical
Therapist’s responsiveness to client
Client’s concerns were satisfactorily addressed by the therapist.
Typical
expressions of dissatisfaction
Client’s concerns were unsatisfactorily addressed by the therapist.
Typical
Note.
For the satisfied group, n
8; for the unsatisfied group, n
8. Frequency of core ideas was analyzed separately for satisfied and unsatisfied
participants. General
appearing in all participant cases (8); Typical
appearing in half but not all participant cases (4 –7); Variant
appearing in 2–3
participant cases.
a Emic aspects of negotiating the therapeutic alliance in cross-racial therapy relationships.
expectations for his Jewish therapist, but observed that “barriers
Three quarters of the unsatisfied clients (6 out of 8) described
started to come into place” after a few months of working together:
instances in which the therapist displayed a lack of awareness of the
dynamics of power and privilege in clients’ lives and in the therapeu-
I guess her being a Jewish woman and my being a Black man made
tic context. In contrast, none of the satisfied clients described this lack
it a little difficult because sometimes growing up in an African
American community where my grandfather was a minister, you’re
of awareness on the part of their therapists. Several of the unsatisfied
expected to act a certain way . . . and she didn’t have first-hand
clients relayed instances in which their therapists minimized their
knowledge of that community. She only had second-hand knowledge,
experiences of discrimination or oppression. For example, an Asian
which she read, or what I told her, or what she heard. It was difficult
immigrant participant told her therapist about participating in a heated
for her to truly understand what I was talking about and the true level
debate on white privilege in a college class, which created tension
of value that I thought that it deserved. A lot of times I thought that
between her and her classmates. Her White therapist responded by
she would minimize some of the things that I was saying, but to me
suggesting that her preoccupation with race was a just a phase she was
they were tantamount, they were just large (laughs). And (hesitates)
the last thing I wanted to hear was that “I know a friend,” or “I have
going through. Other participants described feeling as though their
a friend who is Black”. That I didn’t want to hear in therapy, and that
therapists held racial/ethnic stereotypes or biases, which led to feel-
is what I heard.
ings of mistrust and undermined the therapist’s credibility.

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CLIENTS’ EXPERIENCES OF CROSS-RACIAL THERAPY
529
Self-disclosure.
Therapist self-disclosure was another discrim-
Personal Characteristics
inating feature associated with treatment satisfaction. Even though
we adopted an inclusive definition of therapist self-disclosure for
Attentive versus disengaged.
Attentiveness, or lack thereof,
coding purposes, the majority of self-disclosures described in-
was mentioned by the majority of participants, suggesting that this
volved the sharing of personal factual information versus self-
is an essential trait for the therapeutic relationship. Overall, half of
involving or process-related disclosures (McCarthy & Betz, 1978).
the participants (8 out of 16) described their therapists as attentive,
Approximately half of the self-disclosure examples concerned
caring, and sensitive. Seventy-five percent of the participants who
REC issues (e.g., therapist REC identity, experiences of discrim-
expressed this view were from the satisfied group, whereas only
ination or oppression), whereas the other half involved disclosures
25% were from the unsatisfied group. Therapists with these traits
of personal history (e.g., marital/parental status, places lived or
facilitated clients’ feelings of comfort, trust, and emotional con-
visited, personal experiences of similar problems). Seven out of 8
nection. In contrast, half the participants in the study complained
satisfied participants reported the use of therapist self-disclosure,
about a lack of attentiveness or engagement from their therapist.
compared with only 2 out of the 8 unsatisfied participants. The
Accepting versus critical.
Twice as many unsatisfied clients (4
only satisfied participant who did not experience therapist self-
out of 8) described their therapist as critical, invalidating, or
disclosure indicated that he would have liked his therapist to share
dismissive of their concerns, as compared with their satisfied
more. Further, out of the 7 satisfied participants that reported
counterparts (2 out of 8). These experiences ranged from subtle
therapist self disclosure, all but one reported that the therapist’s
expressions of disapproval involving nonverbal gestures (“I felt
self-disclosure enhanced the relationship. Kareem, a Black man,
that she was just telling me with her eyes to get over it”) to simply
described the profound influence that his White therapist’s self-
the absence of validation, to explicit criticism on the part of the
disclosures about her family life had in making him feel respected
therapist (“I felt like she was always challenging me, but in an
and equal in the relationship:
argumentative fashion”). Conversely, twice as many satisfied par-
ticipants (4 out of 8) described their therapist as nonjudgmental
We were going back and forth. We were having a conversation like
and validating, compared with unsatisfied participants (2 out of 8).
people do . . . . You had to have been there that moment ‘cause you’re
These clients noted that their therapists were accepting and affirm-
looking at this lady, she’s comfortable talking to you, she doesn’t feel
ing and that the therapists normalized their concerns. One partic-
threatened, she doesn’t feel intimidated or scared or anything, and
ipant described this experience in the following way: “[the thera-
(bangs hand on chair) as I would share my experiences with her, and
pist] gave me . . . a ticket, like a pass, like a right to feel a certain
she’s talking to me like it’s no big deal.
way.”
Both of the unsatisfied participants who reported therapist self-
disclosure found the self-disclosure to have a negative effect on
Client Factors
their therapy experience. One gay, politically liberal, Black Latino
male participant reported that his White therapist’s disclosures
Perceptions of the Salience and Meaning of
revealed that he was married, relatively wealthy, and politically
Racial Difference
conservative, which only emphasized the cultural and social dis-
tance between them. The other unsatisfied participant reported that
Perceptions of the salience and meaning of racial differences
his therapist’s self-disclosures were not helpful because they did
differed across the satisfied and unsatisfied groups. Salience was
not have the sort of close relationship required. He notes, “Maybe
assessed with two sources of data, namely (a) the point at which
she thought we were at a different level in the therapy where she
the issue of race emerged in participants’ narratives and (b) the
thought she could do that. I just didn’t like that.” Of the 6
explicit statements regarding the impact of racial differences on
participants with negative experiences whose therapists did not
the relationship. In the first instance, we assigned each participant
engage in self-disclosure, 2 stated that they wished that their
a level of race salience based on a four-category scale, with high
therapists had disclosed more. One of these participants was a
race salience defined as early and spontaneous emergence of racial
Chinese American immigrant who was hoping to share an immi-
themes in the therapy story. Participants who discussed race only
grant connection with her German American immigrant therapist;
in response to explicit interviewer-posed questions regarding the
however, the therapist resisted her attempts to draw on this com-
impact of race on the counseling relationship were viewed as low
monality.
in race salience. Notably, the majority of participants (13 out of
Professionalism and ethics.
Half the sample discussed in-
16) were classified as high in race salience, as evidenced by
stances in which their therapists engaged in what participants’
unprompted discussion of racial themes in the therapy relationship.
described as unprofessional or unethical behavior. These instances
Of the 13 participants, 8 were in the unsatisfied group, whereas 5
were more often described by unsatisfied participants than by
were in the satisfied group, suggesting that racial differences were
satisfied participants (5 out of 8 versus 3 out of 8, respectively).
salient for the majority of the sample, regardless of overall treat-
Examples included coming to sessions late or canceling sessions
ment satisfaction.
altogether, answering the phone or doing paperwork during the
However, there was a qualitative difference in the meaning
session, or violating confidentiality. Such behaviors made the
attached to racial dissimilarity across groups. All of the satisfied
client feel disrespected and led to perceptions of the therapist as
clients praised their therapists for their professionalism and expert-
poorly trained and uncaring. At the other extreme, a few partici-
ness, emphasizing general therapeutic competence and skills rather
pants criticized therapists who were too professional, meaning that
than cultural competence per se. For example, clients described
they focused on maintaining a professional distance at the expense
their therapists as compassionate, nonjudgmental, empathic,
of relating in a personable way.
attentive, and skilled in communication and rapport building.

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CHANG AND BERK
These therapist traits were seen as transcending any barriers that
Client’s Efforts to Bridge Differences
may have arisen as a result of racial differences, as evidenced by
statements emphasizing the universal aspects of human experience
The majority of the sample (11 out of 16) reported that REC
(e.g., “we all have the same needs”) and healing (e.g., “the same
differences presented a barrier to the development of a strong
good advice should work for anybody”). As Ane said of her White
working relationship. Yet half the sample went on to establish a
therapist, “Whatever was inside him, it was good, and that tran-
satisfying and productive relationship with their therapist. Satisfied
scends a lot of things.” These sentiments were not expressed by
and unsatisfied clients differed in their use of two key strategies to
any of the unsatisfied participants.
minimize the impact of perceived difference: compartmentaliza-
tion of race and identification with the therapist.
The majority of satisfied clients also perceived that REC
Compartmentalization of race.
In 80% of the satisfied partic-
factors were unrelated to their presenting problem and goals for
ipants, we observed contradictions in clients’ descriptions about
treatment, which contributed to their diminished importance
the significance of REC in the therapy relationship. In these cases,
in therapy. For example, 1 multiracial participant acknowledged
clients explicitly stated that such issues were secondary, or irrel-
that although his racial and cultural identity was a salient issue,
evant to their presenting problem or the therapeutic work, so that
the fact that his therapist could not fully understand his struggle
it mattered little that their therapists were racially dissimilar.
was not problematic in that he did not see it as factoring into his
However, elsewhere in their narratives, they expressed a clear
depression. Not only did satisfied participants view racial dif-
awareness of the extent to which their presenting concerns were
ferences as exerting a minimal impact on the counseling rela-
shaped by their experiences of being a visible minority. Several
tionship, they also perceived significant advantages of working
revealed psychological conflicts related to their racial or ethnic
with a racially dissimilar therapist. These advantages included
identity, although most did not draw a link between their own
(a) that it was easier to discuss some issues that would have
ambivalence about racial/ethnic issues and their minimization of
been awkward discussing with a therapist of the same back-
difference in the therapeutic relationship. Rather, it appeared that
ground (e.g., sexuality; 3 participants), (b) that racially different
they attempted to resolve any potential sources of internal and
therapists offered a broader perspective that clients could learn
external conflict by deemphasizing the importance of race in their
from (4 participants), and (c) that Whit