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The Impossibility of Client--Therapist "Match": Implications and Future Directions for Multicultural Competency.

Therapist multicultural competence has significant mental health implications for clients. The realization that variation in worldviews and values between clients and therapists may affect client experience and outcome in therapy necessitated a movement toward therapist multicultural competence, spurring ethical guidelines put forth by professional organizations, including the American Counseling Association (ACA, 2014; Ratts, Singh, Nassar-McMillan, Butler, & McCullough, 2016). In recent years, therapist multicultural competence has been identified as a pathway to improve therapeutic outcomes and experiences among individuals who belong to racial and ethnic minority groups (Kim, 2011; Meyer & Zane, 2013). For example, based on racial and ethnic background, individuals enter and exit treatment at different rates: White individuals are more likely to enter treatment and less likely to drop out prematurely (Chu, Leino, Pflum, & Sue, 2017). Counseling professionals have been found to engage clients in treatment at different rates, such that clients with stereotypically White-sounding names are more likely to receive a callback from a counseling center, promoting (rather than impeding) service utilization (R. Shin, Smith, Welch, & Ezeofor, 2016). In addition, racial and ethnic minority clients may be less likely to attend scheduled counseling sessions (Kivlighan, Jung, Berkowitz, Hammer, & Collins, 2018).

Historically, the field of psychology has not supported a culturally informed perspective on practice and research, but in recent years, clinicians have become ethically mandated to practice in a culturally competent fashion (Kagnici, 2014). Widespread efforts to incorporate a sense of multiculturalism in counseling and psychology fields have aimed to alleviate such racial and ethnic disparities in therapy process and outcome. In the past several decades of clinical psychotherapy research, researchers and clinicians have examined racial, ethnic, or cultural match between client and therapist as an important predictor of process and outcome in therapy (e.g., Fuertes, Mueller, Chauhan, Walker, & Ladany, 2002). An overwhelming number of studies have examined these issues, with methodological rigor improving over time, moving from analogue studies to more highly controlled therapeutic outcome studies (Karlsson, 2005). As the number of studies on client-therapist match increased, reviews of the literature were conducted to summarize findings across studies. By our count, there have been at least 16 narrative and five meta-analytic reviews on client--therapist match.

Previously published narrative reviews have examined preferences, perceptions, therapeutic process (e.g., therapeutic alliance), and therapeutic outcomes (e.g., dropout, utilization, level of functioning; Abramowitz & Murray, 1983; Atkinson, 1983, 1985; Atkinson & Schein, 1986; Flaskerud, 1990; Jewel, 1994; Karlsson, 2005; Leong & Gupta, 2008; S. Sue, 1988; S. Sue & Lam, 2002; Vasquez, 2007). More recently, meta-analytic reviews, which use a statistical approach to combine and examine results across many studies, have examined the effect size of match preferences, perceptions, and therapeutic outcomes (Cabral & Smith, 2011; Coleman, Wampold, & Casali, 1995; Maramba & Nagayama Hall, 2002; S. Shin et al., 2005), as well as the effectiveness of culturally adapted interventions (Griner & Smith, 2006; Soto, Smith, Griner, Rodriguez, & Bernal, 2018).

The present review contextualizes the literature on client-therapist match, discusses the challenges associated with research in this area, and presents recommendations for fostering multicultural competence among trainees. The present review draws from the work of intersectionality theory (Cole, 2009; Crenshaw, 1991; McCall, 2005) to contextualize the match literature and be responsive to recent developments in the field in terms of how identities influence experience. Intersectionality describes a particular approach to understanding individuals' experiences as a result of multiple simultaneous, inseparable identities based on their social group memberships (Cole, 2009). The intention of the present review is to concisely critique literature in the area of client-therapist match, discuss intersectionality as it relates to understanding "match" between therapists and clients, describe multicultural competence as a necessity given the impossibility of "match," and provide implications in the form of insights for promoting multicultural competence via education, training, and supervision.


The previous decades of research on client-therapist match were guided by theories of social psychology (Cabral & Smith, 2011), which posited that a similar worldview would foster likeness and interpersonal attraction (Byrne, 1971). Individuals' worldviews--or their particular understanding or conceptions of the world around them--are related to their cultural background, experiences, assumptions, values, beliefs, and biases (Ratts et al., 2016). Inherent in matching clients and therapists on identity variables is the notion that such a similarity provides a sense of comfort and understanding, such that clients would prefer to work with therapists who are similar to themselves. A wealth of research in social psychology supports this notion, with findings that perceived similarity builds credibility and trust while reducing stereotyping (Ames, 2004; Simons, Berkowitz, & Mover, 1970).

Although much social psychological literature supported these findings, when applied to match, studies found mixed results. Previous narrative and meta-analytic reviews of the match literature have found that across studies, people of color tend to prefer therapists of their own race/ethnicity. However, match did not improve client outcomes in a clinically meaningful way (Cabral & Smith, 2011; Maramba & Nagayama Hall, 2002; S. Shin et al., 2005). Because individual studies and literature reviews found mixed results or a lack of significant results for the effect of match on therapeutic outcome, some doubted the utility of matching and suggested a moratorium on client-therapist match research (Alladin, 2002; Lambert et al., 2006).


Social psychological theories of similarity and attraction suggest that clients and therapists who perceive themselves to be similar may work more successfully together in therapy. However, reviews of the match literature to date have not found a clinically meaningful effect of racial, ethnic, or cultural match on therapeutic outcome across studies. Past reviews have described issues in conceptualization and methodology of previous studies regarding match (e.g., Alvidrez, Azocar, & Miranda, 1996; Erdur, Rude, & Baron, 2003; Helms & Carter, 1991; Karlsson, 2005; Nagayama Hall, 2001; S. Sue, 2003). For example, definitions of ethnicity and culture have often varied largely across studies, leading to challenges in comparing and summarizing findings. The constructs of race, ethnicity, and culture have been used interchangeably or without providing a description of how they were measured, defined, or interpreted (Karlsson, 2005). Furthermore, in many early studies, a single question of self-reported identity was used that often lacked adequate validity or sensitivity to the construct being assessed (e.g., level of acculturation; Sanchez & Atkinson, 1983).

To this point, many studies that examined racial, ethnic, and cultural matching in therapy dyads used an ethnic gloss, an overgeneralization or simplistic categorical label used to describe ethnocultural groups, to describe participants (e.g., Asian American; Trimble & Bhadra, 2013). The use of ethnic gloss in research methodology restricts a more comprehensive description of the sample and reduces analysis to a circumscribed understanding of what entails a "match" given the complexity and heterogeneity within identity categories. As such, both external validity and internal validity are compromised by the use of ethnic gloss.

A critical issue that often goes unaddressed in the client-therapist match literature is the notion that participants may not embrace values or attitudes that are traditionally characteristic of their heritage culture (Atkinson & Lowe, 1995; Karlsson, 2005). Considerable heterogeneity' exists within cultures (Altarriba & Bauer, 1998). For example, therapists and clients who share similarities in terms of race, ethnicity, or culture may be highly dissimilar based on the set of norms, values, beliefs, and identifications that they hold (Cabral & Smith, 2011). A client who immigrated from rural Mexico to the United States may not share much cultural understanding with a Cuban American therapist who grew up in Miami, Florida, and whose family immigrated to the United States during the Great Depression. Thus, therapists and clients who share the same or similar identities may have very little in common despite a broad categorical similarity on race or ethnicity, such as Latinx ethnicity in this example. In this case, rather than assume they may implicitly understand one another based on their shared identities, the client and therapist could explore and clarity values, beliefs, and identifications that may inform the therapeutic context.

Intersectionality theory (Cole, 2009; Crenshaw, 1991; McCall, 2005; Moradi & Grzanka, 2017) describes how social identities are overlapping, intersecting, and interconnected and, as such, should be examined in tandem. Intersectionality theory has a general focus on how intersecting social identities may differentially render an individual more likely to experience privilege or oppression. For example, a White heterosexual woman experiences gender oppression but racial and sexual orientation privilege, whereas a Black lesbian woman experiences oppression due to race, gender, and sexual orientation. Whereas previous research tended to focus on identities in isolation, such as race or gender match, an intersectional focus would necessitate a reconsideration of what constitutes a "match."

Because of the multifaceted, dynamic nature of identities, it would be nearly impossible to perfectly match therapists and clients on every given identity variable (e.g., race, ethnicity, socioeconomic status, gender, sexual orientation). Moreover, the concept of client--therapist match may assume that having such a similarity would lead to greater understanding and improved therapeutic outcomes, without consideration of salience of identity. Thus, a nuanced approach to match that considers multiple overlapping identities in conjunction with salience of identity may more adequately capture the complexity of identities and what "match" between a client and therapist would be.

Though much research on client-therapist match has focused on race and ethnicity, researchers have begun to focus on how factors like gender, socioeconomic status, acculturation level, or sexual orientation (among others) might influence therapeutic outcome (e.g., Flaskerud, 1990; Karlsson, 2005; Zane et al., 2005). However, because client--therapist match could exist across many, one, or none of these identities, and the identities could be more or less salient to clients, the assessment of what truly encompasses a match has become complex to define and measure. As the match literature is reduced to inconclusive findings, therapist multicultural competence presents itself as a path forward to improve therapeutic outcomes among marginalized groups.


In our opinion, therapist multicultural competence may be the answer to the questions posed by researchers on this topic, given the challenge and complexity associated with client--therapist match. Although discussions of multicultural competence have existed in the literature approximately as long as research on match, we argue that the former presents a more viable path to ensuring that psychological treatment works for all clients. Multicultural competence represents the therapist's skill set or ability to work effectively with clients of different cultures and backgrounds.

The tripartite or three-dimensional model of multicultural competence is the most commonly used conceptualization of this construct. It defines competence as having (a) knowledge and understanding of the group and its history; (b) awareness of one's beliefs, biases, and attitudes; and (c) sufficient skills to provide culturally sensitive intervention and assessment (D. Sue et al., 1982; D. Sue, Arredondo, & McDavis, 1992). Specific skills within the construct of multicultural competence have been outlined, and the emphasis is placed on this as a skill set in constant development that is never fully achieved (Ratts et al., 2016).

Given the critical importance of multicultural competence in relation to therapeutic outcomes (e.g., Owen, Tao, Leach, & Rodolfa, 2011; Worthington, Soth-McNett, & Moreno, 2007), training programs must continue to emphasize and foster its development among therapists-in-training. Based on the present status of this focus in clinical and counseling programs, we suggest several recommendations that may improve education, training, and supervision. Although many programs currently incorporate multiculturalism into their coursework and practicum experiences, past research demonstrates a significant need for greater emphasis in this area (e.g., Sehgal et al., 2011).


Past studies suggest that multicultural competence, sensitivity, and humility can deepen therapists' understanding of cultural differences and can positively impact racial and ethnic minority clients' experiences in therapy (Zane et al., 2005)--actions that are also intended to result from client-therapist match. Multicultural competence fosters a contextual and experiential match between clients' and therapists' external realities and an intrapersonal feeling of being understood and empowered, which is theorized to improve clinical engagement, treatment, retention, and outcomes (Chu, Leino, Pflum, & Sue, 2016). Researchers have recently begun to create measures to assess therapist multicultural competence broadly (e.g., Gillem et al., 2016) and with specific groups (e.g., Arab Americans; Khoury & Manuel, 2016). Using measurable outcomes to assess therapist multicultural competence will lead to a better understanding of how certain therapists differ in their effectiveness at reducing psychological distress across clients of diverse backgrounds (e.g., Hayes, McAleavey, Castonguay, & Locke, 2016).

Although therapists are known to evidence differences of a small effect size in their effectiveness in working with racial and ethnic minority clients (Haves et al., 2016), measuring and improving therapist multicultural competence is a pathway to reducing these disparities across therapists. We provide a discussion on these competencies in areas of counseling education, training, and supervision. We also use a case example (see below) to discuss how intersectionality of identity and an intersectional view of match may inform counseling practice.


Multicultural competence training deserves greater emphasis in graduate programs across the country. Current accreditation standards emphasize and/or require incorporation of courses on multiculturalism and cultural issues (ACA, 2014), but these courses are much more common in counseling psychology than clinical psychology programs (Sehgal et al., 2011). Additionally, the required focus on multicultural competence in training programs does not guarantee development of competence in trainees. The Council for Accreditation of Counseling and Related Educational Programs (CACREP, 2015) has 13 standards related to multicultural competence in training, yet studies have found no difference in self-reported competence between CACREP and non-CACREP trained counselors (e.g., Barden, Sherrell, & Matthews, 2017; Holcomb-McCoy & Myers, 1999).

In the past few decades, there have been numerous proposals for multicultural education programs. Most programs involve courses that incorporate multicultural awareness, typically via one or two classes using a didactic approach (Brooks, Kim, Move, Oglesby, & Hargett, 2015; Kagnici, 2014). Kagnici (2014) reported that although these courses offer advantages toward improving multicultural counseling skills, a more hands-on approach is necessary for students to benefit. One opportunity that could provide experiential learning includes international immersion experiences offered within some training programs (Kratzke & Bertolo, 2013). The specific goals include enhancing coursework by integrating a multicultural curriculum, acknowledging the established multicultural training standards, generating multicultural awareness, and encouraging international exchanges. Training programs that emphasize immersion or experiential learning techniques may allow for racial and ethnic identity growth and increase awareness and knowledge among students, which are pivotal aspects of multicultural competence.

There is some, albeit limited, research on immersion systems for multicultural counseling training that suggests immersion projects can increase cognitive, empathetic, and emotional responses from participants. These responses are theorized as related to multicultural competence (Ishii, Gilbride, & Stensrud, 2009). Ishii et al. (2009) analyzed the opinions expressed in journals of students who had participated in a 1-week immersion project in Mexico. The journals were used to assess whether the students had successfully achieved the educational goals necessary for their program, and they indicated that broadening of cognitive and emotional awareness had occurred. However, the study did not examine the aforementioned associations with multicultural competence dimensions, and it could not be determined whether the students had truthfully developed more meaningful connections and bonds with the native Mexicans (Hipolito-Delgado, Cook, Avrus, & Bonham, 2011).

A specific training program has been developed to address competency dimensions (awareness, competency, and skills) and to provide direct contact with a given population. The Multicultural Action Project (MAP; Hipolito-Delgado et al., 2011) involves students choosing a population culturally different from them in one or more wavs and developing an action plan with that population that will help facilitate educational and professional goals established at the beginning of the course (Hipolito-Delgado et al., 2011). Students learn the community needs and values through direct interaction, research, and volunteering to promote the community's needs. Three students of the MAP program were asked to document their experiences in journals, and the narratives gave a first-person account of how the students believed they progressed in awareness, skills, and knowledge related to themselves and their chosen population. Participants demonstrated valuable gains in cognitive awareness and empathic reaction (Hipolito-Delgado et al., 2011). Results underscored the need for interpersonal contact in immersion projects, as students who had more interpersonal contact were more capable of formulating insight. These findings indicate that an experiential approach may be an effective way to foster multicultural competence for therapists-in-training. Other international educational programs have been created to resemble typical study-abroad courses (Davies, Lewis, Anderson, & Bernstein, 2015) to improve cultural sensitivity, transformational learning, and empathy.

Another issue in multicultural counseling education is that most courses are designed to educate White therapists on how to work with racially or ethnically diverse clients (Seward, 2014) but do not attend to training therapists of color who will likely work with many White clients. Unique concerns exist for therapists of color working with White clients, such as greater likelihood of experiencing challenges to their expertise and credibility by White clients (Okun, Chang, Kanhai, Dunn, & Easley, 2017). Preparing therapists-in-training who hold minoritized identities (i.e., identities within social groups that are afforded less power or have less representation than other members or groups in society) to work with clients of a social majority group is critically important. This may include education on adaptive strategies to bridge cultural differences and cope with racial microaggressions (Okun et al., 2017), which are everyday subtle, often automatic insults directed toward marginalized groups in society (D. Sue, 2010). Such training would better accommodate the needs of training therapists who may experience oppression within the context of therapy (e.g., Beliard, Cunningham, Fontus, & Move, 2018).

Courses that hold students accountable for their effort and growth and that include experiences to promote commitment to social justice may promote cultural awareness and multicultural competence (Hipolito-Delgado et al., 2011). Faculty teaching multicultural coursework may facilitate trainee self-awareness and growth through incorporating critical race dialogues in training (Chung, Bemak, Talleyrand, & Williams, 2018). Although CACREP-accredited programs aim to increase the emphasis on multicultural competence, many programs have only one such course, and the responsibility of teaching these courses is on junior faculty (Brooks et al., 2015).


Measures of multicultural counseling competence suggest that even graduates of programs requiring a course on multiculturalism and diversity are still not as competent as colleagues with experience in counseling diverse populations (Sehgal et al., 2011). Direct training in culturally responsive treatments and client-centered case consultation has been found to improve cultural competence scores among training therapists working with diverse clients. Therapists who were trained in a culturally responsive model of cognitive-behavioral therapy and engaged in case consultation weekly demonstrated higher multicultural competence scores (Jones, Kawena Begav, Nakagawa, Cevasco, & Sit, 2016).

Other ways to incorporate more experiential, hands-on training with diverse cultures could be implemented at the clinical training level of programs. Most graduate-level programs require a practicum or clinical segment for degree completion (Sehgal et al., 2011). Ensuring that the clinical sites partnered with the school are culturally diverse and students are placed at sites with demographics and cultures different from their own could be viable options for policy development that would give students more experiences working with diverse clientele.

Examples exist in the literature of multicultural therapy practica designed to provide trainees with direct clinical experiences with culturally and linguistically diverse clients (e.g., Kuo & Arcuri, 2014). For example, Kuo and Arcuri (2014) detail a collaboration between a university and a community agency that used a service-based training model to address the underserviced mental health needs of a local refugee community. As a result of the multicultural practicum, trainees reported increased multicultural skills, feelings of self-efficacy, and awareness of cultural issues after providing direct clinical services to refugee clients (Kuo & Arcuri, 2014). This is a concrete, alternative option that programs can consider as a way to provide diverse training experiences for their students.


Implementation of competency training can also be done at the supervision level. Clinical supervision is acknowledged as central to professional development (Bernard & Goodyear, 2014), and supervisors have both a professional and an ethical responsibility to address multicultural issues (ACA, 2014; Bernard & Goodvear, 2014; Peters, 2017). As students are developing their skills in practicum, immersion, or clinical settings, trained clinical supervisors should integrate multiculturalism into the supervision setting to provide students with opportunities to continue building multicultural competence.

The supervisory relationship is essential to effective supervision, and it should be sufficiently strong so as to attend to the multicultural contexts of both therapy and supervision. Supervisors should consider a collaborative approach that honors history, creates trust, and cultivates critical reflexivity among trainees (Arczynski & Morrow, 2017). For example, individual supervision provides an intimate context in which supervisors and trainees can discuss and refine their understanding of the way in which social identities of the therapist and client impact the therapy process (Bernard & Goodyear, 2014). To develop multicultural competence with supervisees, supervisors can: discuss experiences of oppression; reflect on beliefs, values, and worldviews; address privileges, awareness of privilege, and ignorance; describe cultural barriers or differences; use self-disclosure to model discussions of identity; consider identity status and development; broaden and challenge assumptions and biases; and model and develop critical consciousness (Peters, 2017), or the reflexive ability to think critically about the world as socially constructed, recognize and analyze systems of inequality, and commit to take action against these systems (El-Amin et al., 2017).


A Latina counselor, Janice, was working with a client who was a recent immigrant to the United States from Venezuela. Janice was a second-generation immigrant who was born in the United States; her parents immigrated from Spain as children. Janice's first language was English, but she was bilingual and competent to offer clinical services in Spanish under the supervision of a bilingual clinical supervisor. The client, Selena, was a native Spanish speaker who learned English in her youth. Selena was more comfortable speaking Spanish, and the sessions often entailed code-switching between languages. However, Selena and Janice were familiar with different dialects of Spanish.

Janice and Selena shared a strong rapport despite only working together for two sessions when they experienced a rupture. Selena, who identified as a bisexual woman, stated that she met a cute woman whom she was considering asking out on a date. Janice was listening to Selena discuss the prospects of asking out this individual. Janice tried to provide a restatement of what Selena was conveying, and she used the Spanish word mona, meaning "cute woman" in Spain. However, in Venezuela, where Selena was from, mona indicated a conceited woman.

For a moment, Selena seemed hurt that her therapist was implying that she was interested in someone who was conceited or selfish. Selena was quiet for a moment, and then she clarified that she didn't assume that about this person from what she knew. Janice, realizing something happened between herself and Selena, asked her how she was feeling based on what Janice had said. Janice and Selena soon realized the miscommunication, and they were able to share a laugh over their mutual confusion. The rupture was repaired fairly easily on a simple dialectal difference.

However, despite sharing a mutual Latinx background, Janice and Selena were from two highly dissimilar places with different social, historical, and political contexts. Janice lived in the United States her entire life, and Selena had only recently arrived. Selena told Janice about her view that Latinx women should adhere strongly to marianismo beliefs, or prescribed traditional Latinx gender role norms. Selena expressed distress over the Latinx woman she knew in the United States who were less traditional and who did not demonstrate how a Latinx woman should care for her family's unity or spirituality, for example. Although Selena did not know this about Janice, who had not self-disclosed her own gender role beliefs, Janice and her partner shared egalitarian gender roles in their relationship that did not reflect the traditional marianismo beliefs. In addition, Janice identified as an atheist and did not place much importance on spirituality in her family. Janice listened to Selena describe her feelings of distress over the lack of traditionalism increasing among her recently arrived Latinx friends, when Selena said, "You get it, don't you? What do you think about Latinx women who put themselves before their families?"

Although Janice believed that she and Selena might share similar worldviews based on their Latinx backgrounds and the strong rapport they shared, this case demonstrates that therapists and clients who share certain identities in common may not have many similarities in practice. In fact, Janice and Selena both held very different views about how a Latinx woman should behave with respect to her family. Their dissimilarities in terms of sexual orientation, religious background, ethnic background, and acculturation level contributed to intersectional identity differences that manifested in their sessions. Janice had to be aware of how their shared Latinx identity could be a benefit that she believed had improved rapport initially, yet also could lead to sensitive differences between herself and her client with more traditional beliefs.


This review provides an updated critique of the client--therapist racial, ethnic, and cultural match literature based on the recent attention to intersectional identities that merit greater attention. Based on the lack of effect of match on therapeutic outcome, the challenges of defining and measuring match, and the impossibility of match in practice, the focus of the field has turned to multicultural competence, which has demonstrated efficacy across numerous studies. Multicultural competence is at the heart of counseling and the core of successful therapeutic outcome, yet graduate-level training has major areas for improvement. We provided several concrete recommendations to improve multicultural competency in training programs, including implementation and evaluation of experiential learning tools to promote therapist competence.


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Melissa M. Ertl, Department of Educational and Counseling Psychology, University at Albany-State University of New York; Michelle Mann-Saumier, Department of Psychology, University at Albany-State University of New York; Renee A. Martin, Department of Psychology, University at Albany--State University of New York; Donald F. Graves, Department of Psychology, The Sage Colleges; Jeanette Altarriba, Department of Psychology, University at Albany-State University of New York.

Correspondence concerning this article should be addressed to Jeanette Altarriba, Department of Psychology, Social Science 399, University at Albany, State University of New York, 1400 Washington Ave., Albany, NY 12222. E-mail;
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Author:Ertl, Melissa M.; Mann-Saumier, Michelle; Martin, Renee A.; Graves, Donald F.; Altarriba, Jeanette
Publication:Journal of Mental Health Counseling
Article Type:Report
Geographic Code:1USA
Date:Oct 1, 2019
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