Multiple microaggressions and therapy outcomes: The indirect effects of cultural humility and working alliance with Black, Indigenous, women of color clients.

Abstract

We investigated the association between racial microaggressions and microaggressions against women in therapy and positive therapy outcomes. We also tested the potential intervening roles of cultural humility and working alliance in these associations. Participants were a sample of Black, Indigenous, Women of Color (BIWOC; N = 288) who had been in therapy. The sample indicated initial symptom severity and completed the Racial Microaggressions in Counseling Scale, Microaggressions against Women Scale, Cultural Humility Scale, Working Alliance Inventory–Short Form, and the 10-item Schwartz Outcome Scale-10. Bivariate correlations indicated that both forms of microaggressions were negatively related to cultural humility, working alliance, and positive therapy outcomes. Additionally, both forms of microaggressions were negatively related to positive therapy outcomes through cultural humility and working alliance. Exploratory analyses found that (a) BIWOC clients reported higher levels of racial microaggressions from White, compared to Black, Indigenous, People of Color (BIPOC), therapists and (b) the links between both forms of microaggressions and cultural humility were moderated by the race/ethnicity and gender of the therapist, respectively. Cultural humility and working alliance may be important points of intervention in disrupting the impact of microaggressions on therapy outcomes.

Observer and client perceptions of therapist multicultural orientation in a jail setting.

“…Relatedly, higher therapist cultural humility continued to predict a stronger working alliance when accounting for missed cultural opportunities. This supports the MCO literature linking higher therapist cultural humility to stronger working alliance (Davis et al, 2018; DeBlaere et al, 2023; Grad, 2022; Hook et al, 2013, 2017; Owen et al, 2014) and fewer missed cultural opportunities (Owen et al, 2016, 2017).…”

“…The MCO framework is comprised of three constructs: (a) cultural humility (i.e., a relational, other-oriented approach marked by a therapist’s curiosity, openness, and nonsuperiority; Hook et al, 2013; Owen, 2013; Tervalon & Murray-García, 1998), (b) cultural opportunities (i.e., a therapist’s identification of and response to therapeutic cultural markers during session; Owen, 2013; Owen et al, 2016), and (c) cultural comfort (i.e., the degree to which a therapist feels at ease, or lack thereof, when engaging in cultural conversations; (Owen et al, 2017; Pérez-Rojas et al, 2019). Clients who perceive their therapist as more culturally humble report therapists missing fewer cultural opportunities during sessions (Owen et al, 2016), better outcomes (Hook et al, 2013; Kivlighan & Chapman, 2018; Owen et al, 2016), stronger working alliance (DeBlaere et al, 2023; Hook et al, 2013, 2017), and experiencing fewer microaggressions in therapy (Davis et al, 2016; Hook et al, 2016). Clients who perceive their therapist as less attentive to exploring cultural opportunities during sessions (i.e., more missed opportunities) report a weaker working alliance and lower treatment outcomes (Davis et al, 2018; Hook et al, 2013; Owen et al, 2016, 2017).…”

Associations between therapeutic working alliance, meaningful experiences, and affective distress

“…Norcross and Lambert (2018) found that in 306 studies, including over 30,000 clients, the therapeutic alliance had a medium effect counseling outcome in individual counseling ( r = 0.28, d = 0.57). Consistent with common factors literature (e.g., Hubble et al., 2010), the quality of TWA between client and counselor may differ based on client characteristics (e.g., race and ethnicity, gender, and age; DeBlaere et al., 2022; Owe et al., 2011; Vasquez, 2007). Further, clients’ perceptions of the TWA may be developed in a short period of time and remain stable (Horvath & Symonds, 1991) or change over time (Cheng et al., 2021).…”

Automating the assessment of multicultural orientation through machine learning and natural language processing.

“…Owen et al, 2019). Importantly, clients who rate their therapist higher on cultural humility, one of the MCO pillars, report fewer microaggressions (Davis et al, 2016; DeBlaere et al, 2023). Thus, it is imperative to develop methods to equip therapists to effectively work with cultural elements in therapy.…”