Making Therapy Culturally Relevant

         There are some points to consider when thinking about the impact of intersectionality on the therapeutic alliance between therapist and client. Intersectionality commonly considers factors such as age, race, gender, sexual orientation, disability, native tongue, citizenship, religion, and social class in studying how a person's lived experiences, view of the world, and expectations for the future are created and shaped with time.

      While factors such as age, race, sex, physical disabilities, and sexual orientation tend to be visible, disabilities (learning and mental health), social class, citizenship and religion tend to be more hidden. I've observed that clients tend to gravitate to a therapist who shares visible factors in common with them, with age and race being most commonly sought out. Sometimes therapists will discuss on their websites the non-visible factors they experience or have experienced in the past in an effort to convey that they have a particular lived experience in common with their potential clients. Or perhaps they will disclose this if you discuss it in session. 

    The list of non visible shared experiences are endless but for example, being a first or second generation immigrant, having a parent who was a refugee or coming to the country as a refugee, having overcome an addiction, being a parent or single parent, miscarriage or issues with pregnancy, divorce or separation, marital difficulties, being in an interracial relationship, holding precarious jobs or other issues with career, being bullied, experiencing trauma, experiencing sexual assault, going back to school in mid-life, growing up in a particular country, parents divorced when young, learning English as a second language, experiencing challenges with mental health or having a learning disability, and experiencing difficulty with household income as a child.

     When you are in a school, are a client at a community centre or are accessing a therapist through a EAP, there may be just a handful of therapists to select from and you feel they may not be a good fit for you. It is important to invest in your mental health and put a great deal of care in selecting the right therapist for you. It is a crucial investment because your thoughts and feelings shape your destiny. The right therapist can be a huge catalyst for change in your life. Many therapists in private practice offer a sliding scale (even if it isn't advertised) and are willing to work with you to make therapy accessible. 

    When seeking therapy, it is natural for clients to want to seek out a psychotherapist who shares at least a few of these features of intersectionality in common as it suggests they may have had some similar experiences and therefore have a better understanding of what the client is going through. Lived experiences are powerful builders of empathy, because if I remember going through something, or am going through it  myself, and you are now going through the same thing, my understanding comes from the heart and not just the mind. You may be able to convince me out of believing in a theory but not out of my lived experiences. When we share lived experiences, I can see and understand you in ways that other people may not. You are free to speak your personal truth. Taking the risk of being raw in session, and then feeling truly seen, heard and validated in a caring, genuine way is the power of a strong therapeutic alliance. 

     The therapeutic alliance is the single best predictor of meaningful client outccomes. The strength and quality of the therapeutic alliance has been shown to be associated with: positive changes in attachment style in clients (Messer & Gurman, 2011, p. 95), clients being able to access and express their emotions faster and more in-depth while in therapy (Greenberg, 2014) and more profound, long-term behavioural changes after termination (Ardito & Rabellino, 2011; Leszcz, Pain, Hunter, Maunder & Ravitz, 2015). Leszcz et al (2015) state that the therapist’s ability to: convey genuineness and empathy to a client, collaborate on goals, quickly and effectively repair ruptures, and understand the client’s beliefs and worldviews make for a stronger therapeutic alliance. In turn, this helps to create an atmosphere where clients can heal, regardless of the therapeutic style employed (Leszcz, 2018).

     Every therapeutic model has research that demonstrates the effectiveness of its individual techniques on client progress. Examples would be the thought record and exposure therapy in CBT and empty chair and self-critical split techniques in EFT (Josefowitz & Myran, 2017; Elliott, Watson, Goldman & Greenberg, 2004). However, two therapists using the same technique on the same client may have significantly different results, depending on the therapist’s personal characteristics and the quality of the therapeutic alliance they have established with the client (Greenberg, 2018). 

     In emotion focused therapy, the therapist’s presence in creating a safe space for expression of emotions that may have never been made conscious or expressed to others is associated with a high-quality therapeutic alliance (Greenberg, 2014). While the technique used can make a difference, the therapeutic alliance is more important (Greenberg, 2014; Greenberg, 2018). In other words, technical mastery is not enough for meaningful change unless it is accompanied by a high-quality therapeutic relationship. Sensitivity to issues of diversity (Big 7 identities) and equalizing the power helps to cultivate the therapeutic alliance (Moodley, 2011).

     Sometimes you have to try a session or two before you can gauge whether the outcome is likely to be fruitful if you continue to invest the time and effort. Pay attention to how you feel after the session and trust in your intuition to guide you to someone who is the right fit for you.


References

Ardito, R. B. & Rabellino, D. (2011). Therapeutic Alliance and Outcome of Psychotherapy:  Historical Excursus, Measurements, and Prospects for Research. Retrieved from      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3198542/

Elliott, R., Watson, J. C., Goldman, R. & Greenberg, L.S. (2003).  Learning emotionally focused therapy: The process experiential approach to change. Washington D.C.: APA Books.
    
Greenberg, R. (2018). Essential ingredients for successful psychotherapy. In M. J Dewan., B. N. Steenbarger & R.P. Greenberg (Eds.), The art and science of brief  psychotherapies, 3rd edition. (pp. 17-28). Arlington, VA: American Psychiatric Association Publishing
     
Greenberg, L. (2014). The therapeutic relationship in emotion-focused therapy. Retrieved from
http://www.waburkhartphd.com/uploads/1/0/4/5/104505891/
/therapy_relationship_emotion-focus.pdf

Josefowitz, N. & Myran, D. (2017). CBT made simple: A clinician’s guide to practicing cognitive behavioral therapy. Oakland, CA: New Harbinger
 
Leszcz, M., Pain, C., Hunter, J., Maunder, R., & Ravitz, P. (2015). Psychotherapy essentials to go: achieving psychotherapy effectiveness. New York, NY: W.W Norton & Company

Messer, S. B., & Gurman, A. S. (2011). Essential psychotherapies: Theory and practice (3rd ed.). New York, NY: Guilford Press.

Moodley, R. (2011). Outside the sentence. Toronto, ON: Centre for diversity in counselling and psychotherapy