Clients' Race/Ethnicity As a Moderator of the Relationship Between

CLIENTS’ RACE/ETHNICITY AS A MODERATOR OF THE RELATIONSHIP BETWEEN

THE THERAPEUTIC ALLIANCE AND TREATMENT OUTCOME

Yue Li

Submitted to the faculty of the University Graduate School in partial fulfillment of the requirements for the degree Doctor of Philosophy in School of Education, Indiana University August 2020

Accepted by the Graduate Faculty, Indiana University, in partial fulfillment of the requirements for the degree of Doctor of Philosophy

Doctoral Committee

Susan C. Whiston, Ph.D.

Y. Joel Wong, Ph.D.

Lynn Gilman, Ph.D.

Dubravka Svetina, Ph.D.

Date of dissertation defense – April 28th, 2020

Yue Li

iii

Acknowledgements

To graduate with a Ph.D. in Counseling Psychologist was once in my wildest dream, and it feels surreal to wake up and realize that I am now living that dream. Reflecting on this incredible and transformative journey, I would like to express my sincere gratitude to all who have guided and supported me. Without any of you, I would not have become who I am today.

I would like to start by thanking Dr. J. Bruce Overmier at University of Minnesota. When I took your class in 2010, I was a new international student who struggled every week with making even one comment in a small seminar. Thank you for seeing me and taking an interest in me when I had no idea what the future would hold for me. You sparked my American dream.

I would like to thank my mentors and supervisors at University at Albany, SUNY, where I made my first strides in the world of counseling, research, and social justice. I owe deep gratitude to Drs. Alex L. Pieterse and Jessica Martin who looked me in the eye and encouraged me to pursue a doctoral degree. You saw potential in me when I did not see it myself.

To my dissertation committee, thank you for guiding me through this project and providing me with constant support during my study at Indiana University. Thank you, Dr. Lynn Gilman, for your help on data collection and providing important feedback on my dissertation. Thank you, Dr. Dubravka Svetina, for being an amazing stats professor and helping me feel more grounded and confident as a researcher.

To my advisor and dissertation chair, Dr. Susan C. Whiston, I am deeply grateful to you for admitting me to the doctoral program and providing me with support during the past five years.

You are a caring advisor with frank advice and a great sense of humor. I appreciate you encouraging me to pursue a dissertation topic that aligns with my true passion. Thank you for working energetically and persistently with me on many drafts of this manuscript.

To Dr. Y. Joel Wong, I am grateful to you as a thought-provoking instructor, ever- encouraging research mentor, tear-collecting clinical supervisor for the gratitude group (I remember crying every week…), and role model with admirable character. You embody the tireless and intentional expression of encouragement, kindness, and gratitude. You have shown me how to use personal power wisely to generate positive impact on those who have less power.

I will take this cherished lesson with me forever.

To my doctoral cohort, I am so grateful that we have traveled on this journey as a team.

You are brilliant and passionate about social justice research and practice. I would have not grown as much as I did without you.

To my husband Rob who has been there with me through all the years in graduate school, I am proud of what we have accomplished together, including both completing our graduate degrees at IU. Thank you for your patient support as I worked long days and nights. Thank you for seeing my best and tolerating my worst. Our journey has taught me about relationships, vulnerability, and intimacy more than any textbook could ever teach me. I am a better psychologist and person because of you.

To my Dad, thank you for your unwavering support as I pursue my highest dream, even though my dream has taken me to the other side of the globe, far away from you. You instilled in me that I can explore the world and take adventures. You model integrity, groundedness, and living by one’s own principles. You gave me the courage to break free from the confinement of the rigid ideas of how a Chinese woman should live. Your love is selfless and brave. May I be free and fearless.

Yue Li

CLIENTS’ RACE/ETHNICITY AS A MODERATOR OF THE RELATIONSHIP BETWEEN

THE THERAPEUTIC ALLIANCE AND TREATMENT OUTCOME

The importance of understanding racial/ethnic minorities’ (REM) mental health issues and treatment effectiveness is paramount because the American society has become increasingly diverse with regard to race and ethnicity. Whereas psychotherapy process-outcome research has established that the therapeutic alliance is one of the most potent therapeutic ingredients that promotes positive treatment outcome, these studies have involved predominantly White samples.

REM clients may experience psychotherapy differently from White clients considering their oppressed and racialized experience in everyday life as well as in psychotherapy. Therefore, whether the alliance-outcome relationship is as strong for REM clients as it is for White clients warrants further examination. The current study was designed to investigate if there were differences between REM and White clients with regard to the therapeutic alliance and treatment outcome, as well as to test if clients’ race/ethnicity was a moderator of the alliance-outcome relationship. The researcher hypothesized that clients’ racial/ethnic status would moderate the alliance-outcome relationship and that the alliance-outcome relationship would be weaker for

REM clients as compared to White clients. The study used archival data from a training clinic at a large Midwestern university, included 308 Caucasian and 132 REM clients who received counseling services at the clinic. The differences in the therapeutic alliance and treatment outcome measures between the two groups were analyzed by using independent-samples t-tests.

Clients’ race/ethnicity as the moderator was examined by using hierarchical linear regression.

Results of the study indicated that, first, the therapeutic alliance reported by REM clients was significantly lower than that by White clients. Second, there was no significant difference in

treatment outcome between White and REM clients. Third, clients’ racial/ethnic status did not moderate the alliance-outcome relationship, which suggested that there was no significant difference in the strength of the alliance-outcome relationship between White and REM clients.

Findings of the study suggested that, while REM clients who persisted in psychotherapy benefited from it as much as White clients, they experienced a weaker therapeutic alliance. The results of the study highlighted the importance of building an effective therapeutic alliance with

REM clients. Practical implications of the study suggested that therapists should provide culturally sensitive and race-informed psychotherapy in order to build a strong therapeutic alliance with REM clients. Limitations and direction for future research were also discussed.

Susan C. Whiston, Ph.D.

Y. Joel Wong, Ph.D.

Lynn Gilman, Ph.D.

Dubravka Svetina, Ph.D.

vii

TABLE OF CONTENTS

Acceptance Page ...... ii

Abstract ...... vi

Table of Contents ...... viii

List of Tables ...... ix

Chapter I: Introduction ...... 1

Chapter II: Literature Review ...... 11

Chapter III: Method ...... 33

Chapter IV: Results ...... 41

Chapter V: Discussion ...... 46

References ...... 64

Tables ...... 91

Curriculum Vitae

viii

LIST OF TABLES

Table 1. Correlations of the Main Measures...... 91

Table 2. Hierarchical Linear Regression Predicting OQ2 Total...... 93

Table 3. Hierarchical Linear Regression Predicting OQ2 Subjective Discomfort Subscale...... 94

Table 4. Hierarchical Linear Regression Predicting OQ2 Interpersonal Relationships Subscale.

...... 95

Table 5. Hierarchical Linear Regression Predicting OQ2 Social Role Performance Subscale .....96

Chapter I Introduction

The importance of understanding racial/ethnic minorities’ (REM) mental health issues and treatment effectiveness is paramount because American society has become increasingly diverse with regard to race and ethnicity. The 2010 U.S. Census showed that the U.S. population was 60.4% White, 18.3% Hispanic or Latinx, 13.4% Black or African American, 5.9% Asian,

1.3% American Indian and Alaska Native, 0.2% Native Hawaiian and other Pacific Islander, and

2.7% with two or more races. Collectively, REM individuals constitute about 41.8% of the current U.S. population and are projected to exceed the number of White Americans by 2045

(Frey, 2018). In response to these demographic changes, scientific inquiries related to the mental health of REM individuals has become one of the major areas of psychological research, and, more specifically, psychotherapy research (e.g., Comas-Díaz, 2012; Hays, 2016; D. W. Sue & S.

Sue, 2015).

Decades of research with REM individuals suggests that this population is at risk for unique mental health challenges due to their marginalized experience living as racial/ethnic minorities in the United States (American Psychological Association [APA], 2003, 2017). While progress has been made, racism is still deeply embedded in the fabric of the U.S. society, which negatively and profoundly impacts Black American, Latinx American, Asian American, Middle

Eastern American, and Native American’s life experience (Comas-Díaz et al., 2019). The experience of racial discrimination contributes to REM individuals’ racial trauma (e.g., Alvarez et al., 2016b; Bryant-Davis, 2007; Carter, 2007; Comas-Díaz et al., 2019), manifests as psychological and physiological distress (Kaholokula, 2016). Racial trauma is a form of race- based stress that is perpetuated by racial discrimination and microaggression experienced by

REM individuals (Carter, 2007; Comas-Díaz et al., 2019; D. W. Sue et al., 2019). Racial trauma

resembles the symptoms of post-traumatic stress disorder (PTSD), including hypervigilance to threat, flashbacks, nightmares, avoidance, suspiciousness, and somatic experiences such as heart palpitations (Comas-Díaz et al., 2019). The impact of racial trauma is pernicious because REM individuals experience ongoing exposure and re-exposure to race-based stress across their life span (Alvarez et al., 2016a; Comas-Díaz et al., 2019; Helms et al., 2010; Pieterse & Powell,

2016). The experience of racial discrimination also renders negative mental health impact on

REM individuals such as depressive symptoms, negative affect, and somatic symptoms (e.g.,

Nadal et al., 2014; Ong et al., 2013). Moreover, the impact of historical trauma experiences such as slavery, genocide, and colonization can have intergenerational effects. For example, Yehuda et al. (2016) found that the impact of Holocaust may be passed down from an affected parent to an offspring through epigenetic alterations. Sadly, REM individuals may experience the psychological and physiological impact of racial trauma “from the cradle to the grave” (p. 2;

Comas-Díaz et al., 2019).

In an environment in which many REM individuals encounter daily and systemic oppression, psychotherapy could provide a safe, culturally congruent, and empowering space to facilitate REM individuals’ healing (Comas-Díaz, 2016). However, racial disparities in the mental health systems prevail with regard to access to treatment and premature termination (Hall et al., 2020). In 2003, the U.S. Surgeon General issued a comprehensive report on mental health, which explicitly concluded that “most minority groups are less likely than whites to use services, and they receive poorer quality mental health care, despite having similar rates of mental disorders” (p. 3). In addition, studies using nationally representative samples have provided evidence that REM individuals, such as African American, Latinx American, Asian American, and Native American, are less likely to receive mental health treatment compared to their White

counterparts (Alegría et al., 2008; Breaux & Ryujin, 1999; Chen & Rizzo, 2010; Cook et al.,

2007; González et al., 2010; Harman et al., 2004; Harris et al., 2005; Institute of Medicine, 2002;

Richardson et al., 2003; Spoont et al., 2017). Among REM clients who did initiate psychotherapy, research evidence also suggested that a large percentage of them terminated treatment prematurely or unilaterally (Owen et al., 2017; Owoen, Imel, Adelson, & Rodolfa,

2012; Wierzbicki & Pekarik, 1993).

Moreover, research on REM clients’ experience in psychotherapy is in a nascent stage.

While a sizeable literature has investigated therapeutic ingredients that lead to positive treatment outcome in predominantly White client samples, there is a scarcity of studies on the process of psychotherapy that may help REM clients achieve positive treatment outcomes (Flückiger et al.,

2018). Historically, studies using predominantly White client samples have found that the therapeutic alliance is one of the most potent predictors of positive treatment outcome in psychotherapy (Flückiger et al., 2018; Lambert & Barley, 2001; Norcross, 2011). The therapeutic alliance is defined as a collaborative and goal-oriented relationship between the client and therapist (Bordin, 1979). Meta-analyses have shown that the therapeutic alliance contributes to 4.8%-7.8% of the variance in treatment outcome and is arguably the most instrumental therapeutic ingredient that predicts successful psychotherapy (e.g., Flückiger et al., 2018, 2020;

Horvath et al., 2011; Norcross, 2011).

Among REM client samples, the relationship between the therapeutic alliance and treatment outcomes has remained largely unexamined (Comas-Díaz, 2006; Vasquez, 2007).

Researchers have found that a weaker therapeutic alliance reported by REM clients correlates with lower perceptions of the counselor’s general and multicultural competence (Constantine,

2007), lower perceived counselor credibility (Wong et al., 2007), lower client engagement,

higher perceived number of microaggressions (Constantine, 2007), and higher rate of premature termination (Bass & Jackson, 1997; Davis et al., 2015; Davis & Ancis, 2012; Eliacin et al., 2018;

Flicker et al., 2008; Palmer et al., 2009; Robbins et al., 2008; Vasquez, 2007). Few studies, however, have focused on the relationship between the therapeutic alliance and treatment outcome with regard to symptom reduction among REM clients (Flückiger et al., 2013; Walling et al., 2012). Considering the robustness of the alliance-outcome relationship found with predominantly White samples, it is important to examine whether the strength of this relationship differs for REM clients. In other words, research is needed to investigate whether the therapeutic alliance predicts treatment outcome among REM clients in the same manner as it does among

White clients.

One way to examine the difference in strength of the alliance-outcome relationship between White and REM clients is to test clients’ race/ethnicity as a moderator of the alliance- outcome relationship. A moderator is defined as “a variable that alters the direction or strength of the relation between a predictor and an outcome” (p. 116; Frazier, Tix, & Barron, 2004). If clients’ race/ethnicity moderates the alliance-outcome relationship in a sample including both

White and REM clients, it would suggest that this relationship is stronger for one group (e.g.,

White clients) and weaker for the other (e.g., REM clients; Frazier et al., 2004). Previous research has called for more studies to explore whether clients’ race/ethnicity moderates the relationship between the therapeutic alliance and treatment outcome (Comas-Díaz, 2006;

Flückiger et al., 2013). Therefore, the current study was designed to examine the difference in the strength of the alliance-outcome relationship between White and REM clients. That is, clients’ race/ethnicity was examined as a moderator of the alliance-outcome relationship. In

order to test the moderation effect, the researcher first examined the differences in the therapeutic alliance and treatment outcome, respectively, between REM and White clients.

The Therapeutic Alliance

Previous literature suggests that there may be a significant difference in the therapeutic alliance between White and REM clients (Comas-Díaz, 2006; Vasquez, 2007). People across cultures build meaningful relationships differently (Hook et al., 2017b), and therefore, REM clients’ needs and expectations in the therapeutic relationship may be different from White clients’ (Comas-Díaz, 2006). According to Comas-Díaz (2006) and Wampold (2007), mainstream psychotherapy approaches are embedded in Eurocentric biases, which have rendered a monocultural way of building a supportive relationship in psychotherapy. Therapists practicing mainstream psychotherapies may be effective in building the therapeutic alliance with White clients because of the congruence between the therapist and the client with regard to Eurocentric cultural values. However, there may be incongruence in cultural values between these therapists and REM clients. Specifically, Eurocentric biases prevalent in mainstream psychotherapy approaches adhere to the fundamental values of individualism, independence, and linear thinking, while REM clients may come from cultural backgrounds that emphasize interdependence, holism, and circular thinking (Ho, 1987; Sato, 1998). Therefore, it may be more difficult for therapists to build a strong therapeutic alliance with REM clients.

Moreover, REM clients may also experience negative expectations of psychotherapy, cultural mistrust for their therapist, and microaggressions by their therapist in psychotherapy, which have been shown to negatively affect the therapeutic alliance (Hook et al., 2016; Sussman et al., 1987; Terrell & Terrell, 1984; Whaley, 2001). Considering the lack of cultural congruence between REM clients and their Eurocentric therapists, as well as the barriers that REM clients

encounter in building the therapeutic alliance, it was hypothesized in this study that: The therapeutic alliance reported by REM clients is significantly lower than that by White clients

(Hypothesis 1).

Treatment Outcome

Almost seventy years of research has consistently documented the effectiveness of psychotherapy (e.g., Bergin, 1971; Duncan et al., 2010; Eysenck, 1952; Lambert, 2013). Based on meta-analyses, the effect size of psychotherapy is about 0.8, which indicates that an average person who received treatment is better off than 80% of those who did not (Lambert & Bergin,

2013; Wampold, 2010a).

The effectiveness of psychotherapy, however, has traditionally been researched using predominantly White client samples (Comas-Díaz, 2006; Flückiger et al., 2018; Rossello &

Bernal, 1999). More recently, a number of studies have compared treatment effectiveness between White and REM clients and found no significant difference in treatment outcome between the two groups (Drinane, Owen, & Kopta, 2016; Hayes et al., 2016; Hayes, Owen, &

Bieschke, 2015; Imel et al., 2011; Lambert et al., 2006; Ünlü Ince, Riper, van ‘t Hof, & Cuijpers,

2014). Furthermore, findings of these studies suggested that REM clients who received psychotherapy seem to benefit as much from treatment as White clients do (Hayes et al., 2016;

Imel et al., 2011) despite racial disparities with regard to mental health needs and access to care

(APA, 2017; Comas-Díaz et al., 2019; U.S. Surgeon General, 2001). Therefore, in the current study, the researcher hypothesized that: There is no significant difference in treatment outcome between White and REM client (Hypothesis 2).

Clients’ Race/Ethnicity as A Moderator

Investigating clients’ race/ethnicity as a moderator of the alliance-outcome relationship may clarify for which group the relationship between the therapeutic alliance and treatment outcome is stronger (Frazier et al., 2004). Given Hypothesis 1 that REM clients report a significantly lower therapeutic alliance than White clients and Hypothesis 2 that there is no difference in treatment outcome between White and REM clients, it is reasonable to posit that clients’ race/ethnicity is a moderator of the alliance-outcome relationship and that the strength of the relationship is stronger for White than REM clients.

In predominantly White samples, researchers have found several moderators of the alliance-outcome relationship (Constantino et al., 2017; Lorenzo-Luaces et al., 2014, 2017;

Nevid et al., 2017; Piper et al., 2004; Zack et al., 2015). For example, Lorenzo-Luaces et al.

(2015) suggested that clients’ number of prior depressive episodes was a moderator of the alliance-outcome relationship in cognitive behavioral therapy. The alliance-outcome relationship was strong among clients with 0-2 prior depressive episodes, but very weak for clients who had a more significant history of depression. The alliance-outcome relationship was also shown to be stronger for female patients and patients with higher levels of education, indicating the patients’ level of education and gender were moderators of the alliance-outcome relationship (Constantino et al., 2017; Nevid et al., 2017). Moreover, meta-analyses on the alliance-outcome relationship have found that the alliance-outcome relationship appears to be stable and is not moderated by factors such as the rater of the therapeutic alliance, clinical treatment approaches, different alliance scales, and different outcome measures (Flückiger et al., 2018; Horvath et al., 2011;

Horvath & Symonds, 1991; Martin et al., 2000; Zilcha-Mano et al., 2016).

Building upon research on moderators of the alliance-outcome relationship, clients’ race/ethnicity may be another important moderator of this relationship (Comas-Díaz, 2006;

Flückiger et al., 2013). A few studies have investigated the alliance-outcome relationship for

REM clients (e.g., Constantine, 2007; Owen, Leach, Wampold, & Rodolfa, 2011; Pan, Huey, &

Hernandez, 2011). For example, Constantine and Pan et al. found a significant and positive relationship between the therapeutic alliance and treatment outcome for African American and

Asian American clients, respectively. However, the alliance-outcome relationship in these studies was not compared with White clients.

Only two studies compared the alliance-outcome relationship between White and REM clients, and they may provide some preliminary insights on whether clients’ race/ethnicity moderates the alliance-outcome relationship (Flückiger et al., 2013; Walling, Suvak, Howard,

Taft, Murphy, 2012). Walling et al. found that White clients reported a steadily increasing therapeutic alliance as treatment progressed, while the trajectory of the therapeutic alliance reported by REM clients did not exhibit a consistent pattern. These researchers suggested that the alliance-outcome relationship may be stronger for White clients compared to REM clients, but they did not directly examine clients’ race/ethnicity as a moderator of the alliance-outcome relationship. Flückiger et al. conducted a meta-analysis on the alliance-outcome relationship and found that the percentage of REM clients in the samples moderated this relationship.

Specifically, as the percentage of REM clients in the samples increased, the relationship between the alliance-outcome relationship diminished. A limitation of Flückiger et al.’s study was that it did not have the information on the correlation coefficients of the alliance-outcome relationship by racial groups from each study. Therefore, they were only able to test the percentage of REM clients in the samples as a moderator, rather than directly testing clients’ race/ethnicity as a moderator of the alliance-outcome relationship.

Flückiger et al. and Walling et al.’s studies both suggested that the strength of the alliance-outcome relationship may be different for REM and White clients. Given these findings, the current study was designed to examine whether clients’ race/ethnicity moderates the alliance-outcome relationship. It was hypothesized that: Clients’ racial/ethnic status moderates the alliance-outcome relationship in which the relationship is weaker for REM clients

(Hypothesis 3).

Summary

Historically, predominantly White client samples were used by researchers as they conducted the studies on the effectiveness of psychotherapy (e.g., Lambert & Barley, 2001;

Norcross, 2011). The psychotherapeutic process for REM clients may be different from White clients and, yet, less researched (Flückiger et al., 2018; Hall et al., 2020; Wampold, 2007).

Therefore, it is important to understand the psychotherapeutic process for REM clients, and specially, what contributes to successful treatment for REM clients.

Previous research with predominantly White client samples has established that the therapeutic alliance is one of the strongest predictors of positive treatment outcome (e.g.,

Flückiger et al., 2018; Horvath, Del Re, Flückiger, & Symonds, 2011; Norcross, 2011).

However, few studies have examined the therapeutic alliance among REM clients and whether the alliance-outcome relationship is as robust for REM clients as it is for White clients (Comas-

Díaz, 2006; Vasquez, 2007). The current study aimed to examine the differences between REM and White clients with regard to the therapeutic alliance, treatment outcome, and the alliance- outcome relationship. Specifically, the researcher made three hypotheses:

Hypothesis 1: The therapeutic alliance experienced by REM clients is significantly lower than that by White clients.

Hypothesis 2: There is no significant difference in treatment outcome between White and

REM client.

Hypothesis 3: Clients’ racial/ethnic status moderates the alliance-outcome relationship in which the relationship is weaker for REM clients.

In in the following chapter, the researcher will first provide an extensive review of the research on the alliance-outcome relationship that was conducted with predominantly White client samples. Then, the researcher will explore whether REM clients’ experience in psychotherapy diverge from White clients’. Later in the following chapter, the researcher will synthesize studies that compared White vs. REM clients’ experience in psychotherapy, which leads to three hypotheses on whether there are differences in the therapeutic alliance, treatment outcome, and the alliance-outcome relationship between White and REM clients.

Chapter II Literature Review

Decades of psychotherapy research has been conducted in a quest to determine if psychotherapy is effective and to identify which factors contribute to positive outcome

(Chambless et al., 2006; Lambert & Bergin, 2013; Norcross & Lambert, 2018). Psychotherapy has been found to be very effective with an effect size of 0.80 (e.g., Bergin, 1971; Duncan et al.,

2010; Eysenck, 1952; Lambert, 2013), which indicates that an average person who received treatment is better off than 80% of those who did not (Lambert & Bergin, 2013; Wampold,

2010a). Building on this foundation, a number of factors were identified as the active ingredients in effective psychotherapy, such as client variables, treatment modality, stages of change, and the strength of the therapeutic alliance (e.g., Chambless et al., 2006; Crits-Christoph et al., 2011; Lambert & Bergin, 2013; Llewelyn et al., 2016; Orlinsky et al., 2004; Wampold,

2010).

Among all of the of the factors identified, the therapeutic alliance has been found to be one of the most potent ingredients that contributes to positive treatment outcome in psychotherapy (Flückiger et al., 2019; Lambert & Barley, 2001; Norcross & Lambert, 2018).

Meta-analyses have shown that the therapeutic alliance contributes to 4.8%-7.8% of the variance in treatment outcome and is arguably the most instrumental therapeutic ingredient in effective psychotherapy (e.g., Flückiger et al., 2018; Horvath, Del Re, Flückiger, & Symonds, 2011;

Norcross, 2011).

While the discovery of the alliance-outcome relationship has enhanced scholars and practitioners’ understanding of the therapeutic process, research on the process and outcome of psychotherapy has been conducted with predominantly White samples. Thus, the

generalizability of the findings to racially diverse populations is limited (Comas-Díaz, 2006;

Flückiger et al., 2018; Rossello & Bernal, 1999).

REM clients’ experiences in psychotherapy may differ greatly from White clients’

(Comas-Díaz, 2006; Vasquez, 2007), and there is limited understanding about what contributes to effective treatment outcome for REM clients in psychotherapy. Considering the significance of the alliance-outcome relationship found in predominantly White samples, it is important to examine whether this alliance-outcome relationship exhibit the same strength among REM clients. Therefore, the purpose of the study is to investigate the alliance-outcome relationship with REM clients and compare its potency to White clients. In this chapter, the researcher will provide an overview of the research on the alliance-outcome relationship that was conducted with predominantly White client samples. Also included is a discussion of findings that indicate that REM clients’ experience in psychotherapy diverge from White clients. Then, the researcher will synthesize studies that compared White versus. REM clients’ experience in psychotherapy, which leads to three hypotheses on whether there are differences in the therapeutic alliance, treatment outcome, and the alliance-outcome relationship between White and REM clients.

The Alliance-Outcome Relationship with Predominantly White Client Samples

The concept of the therapeutic alliance was initially described in psychoanalytic terms as the relationship between the therapist and the client based on transference (Freud, 1912/1958).

Zetzel (1956) first coined the term of the therapeutic alliance, referring to the patients’ abilities to use the healthy part of their egos to connect with the analyst and work on therapeutic tasks.

Proposing a different approach, Rogers (1957) posited that the therapeutic relationship provides the “necessary and sufficient conditions” (p. 95) for therapeutic change. He suggested that, when the therapist can provide a sense of genuineness, empathy, and unconditional positive

regard, the client will grow and change as a result of this therapeutic relationship. Later, Bordin

(1979) evolved the therapeutic alliance into a pan-theoretical concept and named it the working alliance. He delineated three dimensions of the working alliance: (a) an affective bond between the client and therapist, (b) a mutual agreement on treatment goals, and (c) a mutual agreement on treatment tasks to achieve those goals. The terms therapeutic alliance and working alliance are frequently interchangeable in the literature. Throughout this dissertation, the term therapeutic alliance will be used for consistency.

Decades of empirical research has established that the therapeutic alliance is one of the most potent components of psychotherapy that leads to positive outcome (Flückiger et al., 2018,

2020; Lambert & Barley, 2001). However, as indicated earlier, psychotherapy research has been historically conducted with predominantly White samples (Comas-Díaz, 2006; Flückiger et al.,

2018; Rossello & Bernal, 1999). In predominantly White client samples, the therapeutic alliance has been found to explain a significant amount of variance in treatment outcome (Lambert &

Barley, 2001; Norcross, 2011). Lambert and Barley (2011) summarized the research on treatment ingredients and identified the degree to which certain ingredients contributed to clients’ improvements in psychotherapy. They concluded that, among therapeutic factors that occur within psychotherapy, common factors are the most influential ingredients and explain 30% of the variance in outcome. Common factors include variables found in most theoretical orientations, such as empathy, warmth, and a therapeutic alliance ((Lambert & Barley, 2001).

The therapeutic alliance is the core element of common factors and it is one of the strongest predictors of treatment success (Norcross, 2011). Recently, Flückiger et al. (2018) examined the therapeutic alliance using longitudinal predictor analyses and found that it is a “moderate causal facilitative factor” (p.15) for positive psychotherapy outcome.

Several meta-analyses examined the impact of the therapeutic alliance and found a robust alliance-outcome relationship. Horvath and Symonds' (1991) meta-analysis included 24 studies that measured the “working,” “helping,” or “therapeutic” alliance in clinical samples. They found that the average effect size linking the therapeutic alliance with treatment outcome was .26. The effect size in correlational designed meta-analyses represents the average correlation between the therapeutic alliance and outcome (Rosenthal, 1991). Martin, et al.

(2000) adopted the same inclusion criteria as Horvath and Symonds and found 79 studies in their literature search. Their meta-analysis suggested that the average weighted alliance-outcome correlation was .22. Horvath et al. (2011) synthesized 201 studies using a more detailed coding system and more sensitive statistical analyses to better account for the interdependence within the data. Their results showed that the overall aggregated alliance-outcome relation was .28. In the most recent meta-analysis on the alliance-outcome relationship in adult psychotherapy,

Flückiger et al. (2018) included 295 studies of both face-to-face and internet-based psychotherapy published between 1978 and 2017. They found that the average alliance-outcome association was .28.

Overall, the meta-analyses cited above have consistently found that the alliance-outcome relationship among predominantly White samples ranges from .22 to .28, which means that the therapeutic alliance accounts for 4.8% - 7.8% of the variance in treatment outcome. When interpreting the magnitude of effect sizes, Cohen (1988) made general recommendations that effect sizes of .20 are considered small in magnitude, the ones around .50 are medium, and the ones around or above .80 are large; therefore, using this criteria, the effect sizes for the alliance- outcome relationship would be considered to be in the small range. However, the magnitude of effect sizes should also be judged in reference to previous research findings in one research area

(Durlak, 2009). For example, based on research evidence on the effectiveness of educational interventions on academic achievement, effect sizes around .20 are considered to be of policy interest (Hedges & Hedberg, 2007). Similarly, the effect sizes of the alliance-outcome relationship should also be compared with the strength of the relationships of other treatment ingredients to treatment outcome (Chambless et al., 2006). A series of meta-analyses have aggregated the percentage of variance in treatment outcome contributed by a number of psychotherapeutic factors (e.g., Baskin et al., 2003; Wampold, 2001a; Wampold & Imel, 2015).

According to Chambless et al. (2006), psychotherapy treatment accounts for 13% of the variance in outcome compared to no-treatment, which means that the total variance in clients’ improvement contributed by psychotherapy itself is 13%. Different treatment modalities contribute to about 0% to 1% of the variance in outcome (Chambless et al., 2006). Empirically supported treatment (i.e. manualized treatments that are validated in randomized controlled trials targeting specific disorders; (Chambless & Ollendick, 2001) makes up around 4% of the variance in treatment outcome (Chambless et al., 2006). Therefore, compared to other therapeutic factors, the therapeutic alliance has been found to have an astoundingly robust relationship with treatment outcome and is considered one of the strongest predictors of treatment success

(Castonguay et al., 2006; Norcross, 2011).

While the therapeutic alliance and treatment outcome relationship has been established as strong and robust, cultural differences have remained unexplored. For example, a large number of studies that investigated the therapeutic alliance were with predominately White participants

(75% to 95%; e.g., Constantino et al., 2016; Cooper et al., 2016; Crits-Christoph et al., 2011;

Hatcher & Gillaspy, 2006; Kirouac et al., 2016). Furthermore, many of the studies on the therapeutic alliance and outcome relationship did not even report participants’ racial/ethnic

background (e.g., Andrews et al., 2016; Arnow et al., 2013). In the data set included in Horvath et al.'s (2011) meta-analysis, only 70 out of the 190 of the studies reported participants’ racial/ethnic status, which made it difficult to generalize the findings to clients from specific demographic backgrounds (Flückiger et al., 2013). Moreover, the absence of information on racial/ethnic status in these samples made it difficult to examine race/ethnicity as a moderator between the therapeutic alliance and outcome relationship (Flückiger et al., 2013). Therefore, whether the robust alliance-outcome relationship holds true for REM clients remains unknown.

REM Clients’ Experiences in Psychotherapy

There are a number of studies that indicated REM clients’ experiences in psychotherapy may be significantly different from their White counterparts (Comas-Díaz, 2000, 2006; Vasquez,

2007). However, there is a scarcity of research on the mechanisms within psychotherapy that positively influence treatment outcome for REM clients (Comas-Díaz, 2006; Flückiger et al.,

2018). Many researchers have suggested that psychotherapy is a type of healing practice embedded in the Western and Eurocentric cultural context from which it originated (Comas-

Díaz, 2006; Frank & Frank, 1991; Wampold, 2001b, 2007). Wampold (2007) contended that the therapeutic process is contextual and that the paths to healthy minds are rooted in people’s lived experience and understanding of their problems. REM clients’ lived experience is embedded in their values, religions, cultural norms, and their position in sociopolitical systems, which fundamentally shapes their socialization experiences, ways of coping, and paths to healing (APA,

2003, 2017; Comas-Díaz, 2000, 2006; Vasquez, 2007).

The mechanism of psychotherapy for REM clients may be different from that of White clients given the factors that are uniquely pertinent to REM clients’ experience. Research has shown that REM clients report mistrust of mental health services (Sussman et al., 1987; Whaley,

2001), experience of microaggression in psychotherapy (Chang & Berk, 2009; Constantine,

2007; Hook et al., 2016; Owen et al., 2011; D. W. Sue et al., 2007; Ünlü Ince, Riper, van ‘t Hof,

& Cuijpers, 2014), and racial trauma that is not adequately addressed in psychotherapy (Bryant-

Davis, 2007; Carter, 2007; Comas-Díaz et al., 2019; Helms et al., 2010). These unique factors could significantly impact both the therapeutic relationship and treatment outcome.

Because of the ways in which REM clients’ experience may diverge from White clients’, potent therapeutic ingredients that account for positive treatment outcome for White clients, such as the therapeutic alliance, may not have the same potency in psychotherapy with REM clients.

Therefore, the robust relationship between the therapeutic alliance and treatment outcome, which has been established in predominantly White samples, warrants further exploration with REM clients.

Interestingly, studies that have examined the therapeutic alliance for REM clients tended to focus on its relationship with process variables (e.g., multicultural competence) and dropout rate, rather than treatment outcome in terms of symptom reduction. These studies suggested that a weaker therapeutic alliance is associated with a number of culturally relevant process variables, such as lower perceptions of the counselor’s general and multicultural competence (Constantine,

2007), lower perceived counselor credibility (Wong et al., 2007), lower client engagement, and a higher number of perceived microaggressions (Constantine, 2007). A weaker therapeutic alliance is also linked with higher rates of premature termination (Bass & Jackson, 1997; Davis et al., 2015; Davis & Ancis, 2012; Eliacin et al., 2018; Flicker et al., 2008; Palmer et al., 2009;

Robbins et al., 2008; Vasquez, 2007). For example, Robbins et al. (2008) found a significant relationship between the therapeutic alliance and dropout rate in Hispanic families who attended substance abuse treatment. Based on these findings, the therapeutic alliance may play a vital role

in treatment retention for REM clients (Bass & Jackson, 1997; Davis & Ancis, 2012; Palmer et al., 2009). However, the crucial relationship between the therapeutic alliance and treatment outcome for REM clients has remained largely unexamined and there is a critical need to examine whether this relationship has the same potency with REM clients as it does with White clients.

The current study hypothesized that the magnitude of the relationship between the therapeutic alliance and treatment outcome is significantly different between White and REM clients. Specifically, it is hypothesized that the alliance-outcome relationship is weaker for REM clients compared to White clients. In other words, race/ethnicity is a moderator between the therapeutic alliance and outcome relationship. In order to examine whether the strength of the alliance-outcome relationship differs between REM and White clients, the researcher began with comparing whether the therapeutic alliance and treatment outcome, respectively, differ between

REM and White clients.

Comparing REM and White Clients: Three Hypotheses

The Therapeutic Alliance

Considering the importance of the therapeutic alliance in psychotherapy, it is surprising that very few scholars have focused on the possible differences in the therapeutic alliance between White and REM clients. In her review, Comas-Díaz (2006) speculated that there may be cultural variation in the therapeutic relationship due to differing cultural values and expectations about the therapeutic relationship. She contended that therapists and clients bring their own subjective and contextual experiences into the therapeutic relationship. When therapists and clients come from different cultures, they may negotiate their therapeutic relationship based on different cultural values. For example, a White therapist from a middle-

class background may have biases toward individualism, independence, and linear thinking, while a client from a sociocentric culture may orient their worldview through values such as interdependence, holism, and circular thinking (Ho, 1987; Sato, 1998). Therefore, the alliance building experience between therapist-client dyads of different cultures may be distinctive from dyads that share similar cultural contexts and values (Comas-Díaz, 2006). Hook et al. (2017) provided vivid illustrations that clients as cultural beings are socialized to find emotional comfort and connection with others in ways that are uniquely congruent with their cultural context. For example, in rural South Georgia, meaningful relationships are often built as neighbors have long front-porch conversations as if time does not matter (Hook et al., 2017b). The Eurocentric bias pervasive in mainstream psychotherapy, however, may render monocultural ways of providing care and support in psychological treatment (Comas-Díaz, 2006), which may not be effective in building a therapeutic relationship with clients socialized in different cultural contexts.

Moreover, depending on the cultural understanding of hierarchy, clients from various cultural upbringings often expect the therapist to be like a teacher, a coach, or a family member (Comas-

Díaz, 2006; Vasquez, 2007). Mainstream treatment approaches tend to be Eurocentric, which may be more consistent with cultural values of White clients than that of REM clients. Hence, the formation of the therapeutic alliance in psychotherapy may be more difficult for REM than

White clients.

The Eurocentric biases omnipresent in mainstream psychological treatments may contribute to REM clients’ negative expectations of psychotherapy, which then become barriers to building a strong therapeutic alliance with REM clients (Palmer et al., 2009; Sussman et al.,

1987; Terrell & Terrell, 1984; Whaley, 2001). Among Black and White individuals who experienced depressive symptoms, Sussman et al. (1987) found that a significantly higher

percentage of Black individuals reported negative attitudes toward mental health care compared to White individuals. Specifically, Black participants cited fear of being hospitalized as a barrier that prevented them from seeking professional help for depressive symptoms. In Terrell and

Terrell (1984), 135 African American (AfA) clients were randomly assigned to a Black or White counselor for an intake session. The findings showed that 25% of the AfA clients who met with a Black counselor did not return for a second session, while 43% of those who saw a White counselor did not return. Moreover, they found an interaction between counselor’s race and levels of cultural mistrust reported by AfA clients in predicting clients’ premature termination.

That is, when an AfA client saw a White therapist, the relationship between cultural mistrust and premature termination was stronger; when the AfA client saw a Black therapist, the relationship was weaker (Terrell & Terrell, 1984). Further, Whaley's (2001) meta-analysis suggested that

AfA clients reported similar levels of cultural mistrust in psychotherapy compared to other life situations such as mentoring, career aspirations, social network, and reaction toward racism.

These findings support the notion that REM clients may develop a mistrust of the mental health system because they see it as a microcosm of the injustice in a predominantly White society

(Maultsby, 1982; Ridley, 1984). Literature on the effects of clients’ expectation for treatment suggested that the clients’ expectations about psychotherapy are significantly associated with the therapeutic alliance (Patterson et al., 2008; Tokar et al., 1996; Yuar & Chen, 2011). One study provided a direct link of negative expectations and the therapeutic alliance among REM clients.

Davis et al. (2015) found that that AfA women experienced barriers in developing a strong therapeutic alliance with their therapists. Therapists may be perceived by AfA women as untrustworthy, lacking cultural knowledge, or being unwilling to connect, which weakened the therapeutic alliance and diminished treatment retention. Taken together, REM clients’ negative

expectation about psychotherapy and cultural mistrust of their therapists may become barriers to building a therapeutic alliance.

REM clients may also experience microaggression from their therapists, which negatively affects the therapeutic alliance (Chang & Berk, 2009; Constantine, 2007; Hook et al.,

2016; Owen et al., 2011; D. W. Sue et al., 2007; Ünlü Ince, Riper, van ‘t Hof, & Cuijpers, 2014).

Microaggression is defined as intentional or unintentional putdowns and insults that are experienced by REM individuals in daily life (D. W. Sue et al., 2007, 2019). While the person who commits the microaggression may not be aware of the hostility and insensitivity communicated, the impact of the microaggression is typically hurtful. Unfortunately, while

REM people experience microaggression in everyday life (D. W. Sue et al., 2007), there is evidence that REM clients may experience racial microaggression in psychotherapy as well

(Chang & Berk, 2009; Constantine, 2007; Hook et al., 2016; Owen, et al., 2011). In one study that involved 2,212 REM clients, 81% of them reported experiencing at least one microaggression in counseling (Hook et al., 2016). Research evidence supports the link between the experience of microaggression in psychotherapy and a lower therapeutic alliance. Pope-

Davis et al. (2002) found that therapists’ microaggressions significantly and negatively impacted the therapeutic alliance. Constantine's (2007) findings also suggested that AfA clients’ perception of racial microaggression in psychotherapy was predictive of a weaker therapeutic alliance.

Considering that the process of building the therapeutic alliance is culturally bound, and that REM clients’ negative expectations about psychotherapy and experiences of microaggression in psychotherapy may weaken the therapeutic alliance, the researcher in the current study posited that REM clients will report a weaker therapeutic alliance than White

clients in psychotherapy. Research that directly compared the therapeutic alliance between

White and REM clients is scarce and unclear. In a sample of 152 AfA and White veterans,

Eliacin et al. (2018) found that race was significantly associated with the therapeutic alliance, indicating that AfA clients reported a weaker therapeutic alliance compared to White clients. In another study, Morales et al. (2018) found no significant difference in the therapeutic alliance between White and REM clients at the third session. In summary, few studies that have investigated whether the therapeutic alliance reported by REM clients differed from that reported by White clients and the results were not conclusive. More research is needed in this area, and therefore, the first hypothesis in this study was made regarding the therapeutic alliance between

White and REM clients:

Hypothesis 1: The therapeutic alliance reported by REM clients is significantly lower than that reported by White clients.

Treatment Outcome

Research on the difference in treatment outcome between REM and White clients indicates that psychotherapy is as effective for REM clients as it is for White clients. In other words, there is no significant difference in treatment outcome between the two groups (Drinane et al., 2016; Hayes et al., 2016, 2015; Imel et al., 2011; Lambert et al., 2006; Ünlü Ince et al.,

2014). To compare treatment outcome between REM and White clients while eliminating comfounding factors other than race, Lambert et al. (2006) sampled REM clients in a university counseling setting and matched them with Caucasian clients based on intake score, gender, marital status, and age. The study used OQ-45 (Outcome Questionnaire-45, Lambert et al.,

2004) to measure treatment outcome, which is a previous version of the same outcome measure used in the current study, and found no difference in treatment outcome between any REM group

and its matched Caucasian control group. Ünlü Ince et al. (2014) conducted a metaregression analysis including 56 RCTs (i.e. randomized controlled trials) studies on treating adults with depression and found no difference in treatment outcome based on race/ethnicity. Using a racially diverse sample, Imel et al. (2011) measured days of cannabis use as the outcome for adolescent cannabis abuse treatment. They found that race was not a significant predictor of treatment outcome, indicating that there was no significant difference in treatment outcome between White and REM clients. The focus of Imel et al.’s study was on difference in treatment outcome between White and REM clients at the therapist level effects, but no significant racial difference in treatment outcome was found in general. Similarly, in a sample from a university training clinic, Hayes et al. (2015) found racial difference in treatment outcome at the therapist level; however, the results indicated no outcome difference, measured by OQ-45, between White and REM clients. In a large scale study that included data from 122 university counseling centers, Hayes et al., (2016) found, “on average, REM clients experienced as much reduction in psychological symptoms [measured by CCAPS-62 (Locke et al., 2011)] as did White clients” (p.

266), although some therapists had better outcomes with REM clients and some with White clients.

Despite the fact that REM clients are at risk in terms of greater mental health challenges

(APA, 2017; Comas-Díaz et al., 2019; Hall et al., 2020; U.S. Surgeon General, 2001), results from the aforementioned studies supported the finding that REM clients generally benefit from psychotherapy similarly to White clients. Therefore, the researcher made the second hypothesis:

Hypothesis 2: There is no significant difference in treatment outcome between White and

REM client.

Race/Ethnicity as a Moderator of The Alliance-Outcome Relationship

Building on Hypothesis 1 that REM clients report a weaker therapeutic alliance than

White clients and Hypothesis 2 that REM and White clients achieve similar treatment outcome, it seems reasonable to speculate that the strength of the alliance-outcome relationship is weaker for

REM compared to White clients. In other words, race/ethnicity may be a moderator between the alliance-outcome relationship.

A moderator is defined as “a variable that alters the direction or strength of the relation between a predictor and an outcome” (p. 116; Frazier, Tix, & Barron, 2004). It is important to study moderators in the alliance-outcome relationship because moderators provide conditions of

“when” or “for whom” the relationship between the independent and dependent variables is stronger or weaker (Frazier et al., 2004).

According to Baron and Kenny (1986), moderation analyses may be performed when the relationship between the predictive and outcome variables shows inconsistencies across studies.

Identifying moderators may reveal, for example, whether the intervention is only effective for some people (Frazier et al., 2004). Despite the robust relationship between the therapeutic alliance and treatment outcome, meta-analysis has shown high variability in this relationship,

Q(189) = 498.42, p < .0001 (Horvath et al., 2011). Therefore, potential moderators such as clients’ race/ethnicity warrant further investigation (Zilcha-Mano & Errázuriz, 2015) and could further clarify for which population the therapeutic alliance is a potent therapeutic ingredient.

The following analysis first provided an overview of known moderators of the alliance-outcome relationship in predominantly White samples. Then, the researcher discussed why clients’ race/ethnicity may be a moderator in the alliance-outcome relationship.

Known Moderators in Predominantly White Samples. A small body of research has investigated factors that moderate the alliance-outcome relationship; however, most of these

studies were conducted with predominantly White samples. These factors include treatment length, therapist’s level of theoretical integration, whether clients were given an opportunity to provide feedback, and other client variables, such as attachment style, prior history of depression, symptoms severity, level of education, and gender.

In a sample of psychiatric outpatient clients, Piper et al. (2004) found that the quality of the object relations was a moderator between the therapeutic alliance and treatment outcome in interpretive therapy. The quality of object relations is a personality variable that measures the style in which a person develops relationship with others, which ranges from a more primitive, labile, and destructive style to a more mature, tender, and loving style. The results suggested that patients with higher quality of object relations benefit more from treatment when the therapeutic alliance was strong, while patients with lower quality of object relations benefit more from treatment when the therapeutic alliance was weak. Somewhat contradictory results were found in a study on adolescents who received residential treatment for substance dependence disorders using cognitive behavioral therapy (CBT; Zack et al., 2015). The study found that attachment to the primary caregiver moderated the alliance-outcome relationship and that the alliance-outcome relationship was stronger for youth with poor attachment history and weaker for those who had strong attachment history. These studies suggested that clients’ attachment style may be an important moderator of the alliance-outcome relationship. Patients with varying attachment style may respond to treatment differently depending on how their early attachment experience is enacted in the therapeutic relationship.

A series of studies examined clients’ number of prior depressive episodes as a moderator of the alliance-outcome relationship and how the moderation effect varies with different theoretical approaches. In a sample of clients who received CBT for depression, the number of

prior depression episodes was found to be a significant moderator of the alliance-outcome relationship (Lorenzo-Luaces et al., 2014). For clients with 0-2 prior depressive episodes, the therapeutic alliance was predictive of treatment outcome (r = .52). However, for clients who had had three or more episodes, the alliance-outcome relationship was very week (r = -.02).

Lorenzo-Luaces et al. (2017) extended the previous study and examined patients’ prior history of depression in short-term psychodynamic supportive psychotherapy (SPSP) versus CBT. They replicated the previous results that, in CBT, prior number of depressive episodes moderated the alliance-outcome relationship, indicating that, the more significant the patient’s prior history of depression, the weaker the alliance-outcome relationship. However, in SPSP, the therapeutic alliance was a robust predictor of treatment outcome regardless of prior depression episodes.

These studies indicated that building the therapeutic alliance is an effective passage to positive outcome for clients who had few prior depressive episodes and were treated in CBT. In SPSP, forging the therapeutic alliance may have long lasting impact on positive outcome even for clients who had more significant history of depression.

In a Chilean sample, treatment length, patient symptom severity, therapist’s level of theoretical integration, and patients’ feedback were found to be significant moderators of the alliance-outcome relationship (Zilcha-Mano & Errázuriz, 2015). Specifically, in conditions in which the treatment was longer than six session, patients’ symptoms were more severe, therapists’ approach was more integrative, and patients’ feedback was elicited, the alliance- outcome relationship was stronger.

Moreover, clients’ education level and gender were also found to moderate the alliance- outcome relationship. Constantino et al. (2017) found that patients’ level of education was a moderator of the alliance-outcome relationship, suggesting that the relationship was stronger for

patients who had higher levels of education. Among patients who received acute inpatient treatment, patient gender moderated the alliance-outcome relationship so that the therapeutic alliance only predicted treatment outcome for female patients (Nevid et al., 2017).

In additional to the aforementioned studies, several meta-analyses also shed light on a few variables that may have a moderating effect on the alliance-outcome relation. The results were mixed concerning whether the timing of the alliance assessment influences the alliance- outcome relationship. Castonguay et al. (2006) suggested that the therapeutic alliance assessed early in treatment was more predictive of treatment outcome, whereas, Flückiger et al.'s (2018) meta-analysis found that the alliance-outcome correlation was higher when alliance was measured later in therapy. Flückiger et al. attributed this finding to the possibility that late alliance and outcome were measured closer in time. However, in Martin et al.'s (2000) and

Horvath et al.'s (2011) meta-analyses, the time of the alliance measurement was not a moderator that influenced the alliance-outcome relationship. Therefore, there is no conclusive understanding on when the therapeutic alliance is the most potent in predicting treatment outcome during the course of psychotherapy.

Several factors were also shown by meta-analyses to have no moderation effect on the alliance-outcome relationship. The findings regarding the rater of the therapeutic alliance (e.g., the therapist vs. client) have consistently shown that who rates the therapeutic alliance does not moderate the alliance-outcome relation. An early meta-analysis by Horvath and Symonds (1991) found that clients’ assessments of the therapeutic alliance were more predictive of treatment outcomes than therapists’ and observers’ ratings. However, the type of alliance rater did not appear to moderate the alliance-outcome relation in later meta-analyses (Flückiger et al., 2018;

Horvath et al., 2011; Martin et al., 2000; Zilcha-Mano et al., 2016). Moreover, findings were

consistent with regard to treatment approaches, different alliance scales, different outcome measures, and publication sources; the empirical findings indicated that these factors do not moderate the relationship between the therapeutic alliance and treatment outcome (Flückiger et al., 2018; Horvath et al., 2011; Horvath & Symonds, 1991; Martin et al., 2000; Zilcha-Mano et al., 2016). With regard to length of treatment, Horvath and Symonds found that the length of treatment was not a significant moderator. Later meta-analyses, however, did not analyze the length of treatment as a moderator (Flückiger et al., 2018; Horvath et al., 2011; Martin et al.,

2000). Taken together, research findings suggested that, the type of measure employed in the study, the type of rater assessing the therapeutic alliance, and the type of rater assessing the treatment outcome do not affect the strength of the alliance-outcome relation.

Although the relationship between the therapeutic alliance and treatment outcome and its moderators have been researched in predominantly White samples, little is known about whether this robust relationship holds for REM clients in psychotherapy (Castonguay et al., 2006;

Flückiger et al., 2018). Castonguay et al. (2006) reviewed decades of research on the therapeutic alliance and argued that more attention should be paid to these specific client populations. They specifically pointed out that there was a paucity of research on the alliance-outcome relationship for REM clients. Flückiger et al.'s (2018) meta-analysis also suggested that, except for substance use disorder settings, REM clients were underrepresented in the studies examined in their meta- analysis. Flückiger et al. found that the lack of representation of REM clients in psychotherapy research made it difficult to analyze the alliance-outcome relation for REM populations. More than a decade has passed since Castonguay et al.'s review on the therapeutic alliance research,

Flückiger et al. made the same recommendation concerning the need for more research on the relationship between the therapeutic alliance and treatment outcome among REM client

populations. Studies reviewed in this section (e.g. Flückiger et al., 2018; Horvath et al., 2011;

Lorenzo-Luaces et al., 2017; Zilcha-Mano & Errázuriz, 2015) have identified several moderators of the alliance-outcome relationship using predominantly White samples, which clarified in conditions and for whom the therapeutic alliance is an active agent in promoting positive treatment outcome. Investigating whether clients’ race/ethnicity moderates the alliance-outcome relationship may shed more light on the potency of the therapeutic alliance.

Race as a Moderator of The Alliance-Outcome Relationship. As indicated earlier, few studies have examined the relationship between the therapeutic alliance and psychotherapy outcome for REM versus White clients. Constantine (2007) and Pan et al. (2011) found a significant and positive relationship between the therapeutic alliance and treatment outcome among African American and Asian American clients, respectively. However, their samples did not include any White clients and, therefore, it was not possible to examine whether clients’ racial/ethnic status affected the alliance-outcome relationship. Owen et al. (2011) found a positive relationship between the therapeutic alliance and outcome in a sample of White and

REM clients, but whether that relationship differed between White and REM clients was not analyzed.

Only two studies have examined the therapeutic alliance and treatment outcome relationship for REM versus White clients. In a sample of men perpetrators of intimate partner violence, Walling et al. (2012) measured the trajectory of the working alliance four times during the course of CBT. Research on the trajectory of the therapeutic alliance over time suggested that a linear or stable trajectory is related to greater improvements in treatment outcome (e.g.,

Kivlighan & Shaughnessy, 2000; Piper et al., 1995), whereas a trajectory of a declining therapeutic alliance would occur when the client experiences a difficult time in therapy (e.g.,

when the therapist challenges the client; Gelso & Carter, 1994; Horvath & Luborsky, 1993).

Walling et al. found that the therapeutic alliance ratings among White participants exhibited a pattern of steady growth over time, which signified a positive and effective therapeutic experience. However, no consistent pattern of change in the therapeutic alliance was observed among REM clients. Walling et al.'s findings indicated that it may be more difficult to build the therapeutic alliance with REM than White clients in psychotherapy.

In the second study, Flückiger et al. (2013) conducted a meta-analysis that examined whether the percentage of REM clients in the sample moderated the therapeutic alliance and treatment outcome relationship. Out of 190 studies analyzed by Horvath et al. (2011), Flückiger et al. found 70 studies that provided sufficient information on the percent of REM clients in the sample. Twenty-four additional studies were found and added to the analysis. Flückiger et al. calculated the percentage of REM clients in each selected study and tested whether the percentage of REM clients in the samples moderated the alliance-outcome relationship. Using a random-effects restricted maximum-likelihood model, Flückiger et al. found that the percentage of REM clients in samples partially moderated the alliance-outcome relationship such that the higher percentage of REM clients in the samples, the weaker the alliance-outcome relationship.

It should be noted, however, the samples that contained a higher percentage of REM clients happened to also have a higher percentage of clients with substance use disorder (SUD).

Therefore, it was unclear whether the alliance-outcome relationship in this study was weakened by the higher percentage of REM clients or clients with SUD (Flückiger et al., 2013). While their findings provided preliminary evidence on the impact of race/ethnicity on the therapeutic alliance and outcome relationship, they did not answer the question whether the therapeutic alliance and outcome relationship was stronger or weaker for REM clients compared to White

clients. Flückiger et al. recommended that future research investigate the therapeutic alliance in psychotherapy for REM clients. More specifically, they suggested that a direct comparison between REM and White clients with regard to the therapeutic alliance and outcome relationship is needed.

Taken together, Walling et al. (2012) demonstrated that race/ethnicity influenced the therapeutic alliance and that it was more difficult to build a strong therapeutic alliance with REM clients compared to White clients. In addition, Flückiger et al. (2013) found that the higher percentage of REM clients in the samples moderated the relationship between the therapeutic alliance and treatment outcome. Considering that REM clients experience a weaker therapeutic alliance than White clients (Hypothesis 1) and that REM and White clients achieve similar treatment outcome (Hypothesis 2), the researcher hypothesized that, comparing the alliance- outcome relationship between White and REM clients, this relationship will be weaker for REM than White clients (Hypothesis 3). In other words, clients’ race/ethnicity is a moderator of the relationship between the therapeutic alliance and treatment outcome:

Hypothesis 3: Clients’ racial/ethnic status moderates the relationship between the therapeutic alliance and treatment outcome (measured by OQ45-45.2), in which the alliance- outcome relationship is weaker for REM clients.

The Current Study

The primary purpose of the current study is to examine the therapeutic alliance, treatment outcome, and the alliance-outcome relationship between White and REM clients, using archival data from a counseling training clinic at a Midwestern university. More specifically, the researcher made three major hypotheses.

First, it was hypothesized that the therapeutic alliance experienced by REM clients is significantly lower than that by White clients.

Second, it was hypothesized that there is no significant difference in treatment outcome between White and REM client.

Third, it was hypothesized that clients’ racial/ethnic status moderates the relationship between the therapeutic alliance and treatment outcome.

Chapter III Method

Participants

The current study used archival data from 440 clients who received counseling services at a training clinic at a large Midwestern university. Within the sample, 308 clients identified as

Caucasian (70%) and 132 clients identified as racial/ethnic minority (30%). Of the clients who identified as racial/ethnic minority, 32 clients identified as African American (7.3%), 38 as Asian and Pacific Islanders (8.6%), 31 as Latino/a (7%), 28 as Multiracial (6.4%), two as Arab (0.5%), and one as other (0.2%). With regard to gender, 294 participants identified as female (66.8%),

131 as male (29.8%), nine as gender non-conforming (2%), and six as transgender (1.4%).

Participants’ age ranged from 17 to 68 (M = 25.76, SD = 8.74). Two hundred and ninety-seven participants identified as heterosexual (67.5%), 40 as gay/lesbian (9.1%), 40 as bisexual (9.1%),

22 as questioning (5%), one as asexual (0.2%), 13 as other (3%), 12 preferred not to answer

(2.7%), and in15 cases the information was missing (3.4%). As for relationship status, 317 participants reported to be single (72%), 56 married (12.7%), 25 living together (5.7%), 18 divorced (4.1%), 11 were in domestic partnership (2.5%), seven separated (1.6%), and six cases were missing (1.4%). In terms of work status, 149 participants were employed part time

(33.9%), 119 were employed full time (27%), 102 were unemployed (23.2%), and 70 cases were missing (15.9%). Regarding education level, three participants had no high school diploma

(0.7%), 236 participants’ highest degree obtained was a high school diploma/GED (53.6%), 104 had bachelor’s degree (23.6%), 37 had master’s degree (8.4%), six had Ph.D. (1.4%), and 19 cases were missing.

Archival data for clients seen at the clinic between January 2014 to May 2019 was obtained. The counseling clinic is operated by a counseling psychology program and serves as a

training facility for master’s level and doctoral level practicum students who are supervised by licensed personnel. Clientele involves college students who matriculated at the Midwestern university as well as local community residents. Clients who did not have at least one therapeutic alliance score were excluded from the study.

Measures

Outcome Questionnaire-45.2 (OQ-45.2).

The OQ-45.2 (Lambert et al., 2004) is a self-report measure of psychological functioning.

There are 45 items measured on a 5-point Likert scale (0=never, 1=rarely, 2=sometimes,

3=frequently, 4=almost always). The range of total scores is 0 to 180, with higher scores reflecting higher levels of distress. Clients’ progress is tracked by subtracting the Initial Score by the Most Recent Score; a difference of 14 points signifies “Reliable Change” (Lambert, 2015;

Lambert et al., 2015). Three broad domains of psychological functioning are assessed by OQ-

45.2: (a) subjective discomfort (e.g., “I feel no interest in things.”), (b) interpersonal relationships (e.g., “I am concerned about family troubles.”), and (c) social role performance

(e.g., “I have too many disagreements at work/school.”). The total score of the OQ-45.2 was used in the current study.

Research studies reflect that the total scores of OQ-45.2 have high test-retest reliability (r

= .84; Lambert et al., 1996) and internal consistency (Cronbach’s α = .93; Lambert et al., 2004).

Concurrent validity of OQ-45.2 has also been established with other measures, such as the

Symptom Checklist-90-R (r = .78; Derogatis, 1992), the Beck Depression Inventory (r = .80;

Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), and the Social Adjustment Scale (r = .65;

Weissman & Bothwell, 1976).

With regard to REM client populations, Nebeker, Lambert, and Huefner (1995) tested the internal consistency of OQ-45.2 (Cronbach’s α = .93) in a sample of White and African

American clients. No significant difference in terms of the reliability of the scores on the OQ-

45.2 was found between White and African American clients (Nebeker et al., 1995). The OQ-

45.2’s reliability estimates have also been compared between White and REM client populations such as African American, Asian/Pacific Islander, Latinx, and Native American (Gregersen et al.,

2004; Lambert et al., 2006) and the results indicated that OQ-45.2 may be a reliable measure for

REM client populations.

Outcome Questionnaire-45.2-Therapeutic Alliance (OQ-45.2-TA).

The OQ-45.2-TA (Lambert et al., 2015) is a self-report measure that assesses the therapeutic alliance. It is one of the subscales of the Assessment for Signal Clients (ASC;

Lambert et al., 2015), which measures clients’ social supports, motivation, and stressful life events in addition to the therapeutic alliance. There are 11 items on the OQ-45.2-TA and they are measured on a 5-point Likert scale (1=strongly disagree, 2=slightly disagree, 3=neutral,

4=slightly agree, 5=strongly agree). The range of total scores is from 11 to 55, with higher scores reflecting a more positive therapeutic alliance. The items assess the therapeutic bond

(e.g., “I felt cared for and respected as a person.”), shared goals (e.g., “My therapist and I had a similar understanding of my problems.”), agreement on therapeutic tasks (e.g., “My therapist and

I seemed to work well together to accomplish what I want”), and alliance rupture (e.g., “I felt there was a breakdown in the relationship with my therapist.”; White et al., 2015). Research shows that the OQ-45.2-TA scores have high internal consistency (Cronbach’s α=.87; Kimball,

2010).

Procedure

Archival data from clients who sought services at the counseling clinic between January

2014 and May 2019 were collected. Information obtained included clients’ number assigned by the clinic, date of birth, age, gender, sexual orientation, relationship status, race/ethnicity, work status, and highest degree. The demographic information was completed by clients before their intake appointment and was entered into the clinic’s software system, Titanium, by the intake therapist. The training director of the clinic compiled the needed client information between

2014 and 2019 from Titanium and provided a spreadsheet to the researcher. No identifying information such as clients’ names or email addresses were collected.

Additionally, clients’ OQ-45.2 and OQ-45.2-TA scores was collected. At the clinic, the

OQ-45.2 and OQ-45.2-TA scores were collected via OQ-Analyst, the online assessment tool of

OQ measures. The training director of the clinic compiled clients’ information for clients seen between 2014 and 2019 from OQ-Analyst and provided a spreadsheet to the researcher.

With regard to the measure of the therapeutic alliance, the OQ-45.2-TA questionnaire was administered around every fourth session to monitor clients’ therapeutic alliance with their therapists. These first OQ-45.2-TA scores was used in the data analysis as Castonguay et al.

(2006) suggested using early measures of the therapeutic alliance in examining the relationship between the alliance and outcome.

As for the treatment outcome measure, the OQ-45.2 questionnaire was administered before every appointment including the intake. In the regression analysis, clients’ last OQ-45.2 score was entered as the outcome variable, and the first OQ-45.2 score was entered as a controlled variable.

Data Analysis

All data analyses were conducted using IBM® SPSS® Statistics Version 25. In order to test the three hypotheses, first, the researcher used independent-samples t-tests to examine the differences in the therapeutic alliance and treatment outcome between REM and White clients.

Then, the researcher used hierarchical linear regression analysis to test clients’ race/ethnicity as a moderator of the therapeutic alliance and treatment outcome relationship. The steps of the hierarchical linear regression analysis were delineated as followed.

Variables

The predictive variable was the therapeutic alliance, measured by clients’ first OQ-45.2-

TA score (TA). Clients’ first OQ-45.2 score (OQ1 Total) was entered into the hierarchical multiple regression analysis as a controlled variable. The moderator was clients’ racial/ethnic status (Race). The moderator had two levels: racial/ethnic minority (i.e. clients who identified as

African American, Asian, Asian American, Latino/a, Native American, Pacific Islander, multiracial, and other) and White (i.e. clients who identified as Caucasian). The outcome variable was clients’ last OQ-45.2 total score (OQ2 Total).

Considering Power of Tests of Interactions

A priori analysis of power was conducted using G*Power (UCLA: Statistical Consulting

Group, n.d.). G*Power analysis suggested that a sample size of 395 was needed in order to detect an effect size of f2 = .02 with power of 0.80, which indicated that the current sample size of 440 is sufficient.

Whether the sizes of samples between White and REM clients was even was considered because unequal sample sizes decrease power (Frazier et al., 2004). In the current dataset, the sample size proportion were .3/.7 (i.e. 132 REM vs. 330 White participants). The unequal

sample sizes in the current sample may present as a problem and are discussed later in the limitations section.

Moreover, the assumption of homogeneous error variance was examined to ensure that error variances across groups are equal (Frazier et al., 2004). Plots of residuals were used to check the assumption of homogeneity of variance (King et al., 2010). The standardized predicted scores (zpred) were plotted against the standardized residuals (zresid) to diagnose issues with the assumption of homogeneity of variance, for example, whether the residuals were normally distributed around the predicted outcome variable (King et al., 2010). The examination of assumptions of multiple regression are discussed in the results section.

Representing Categorical Variables with Code Variables

Since the moderator, clients’ racial/ethnic status, was categorical, this variable needed to be transferred into code variables (Frazier et al., 2004). Effects coding was applied to clients’ racial/ethnicity status because comparisons with the grand means between White and REM clients were desired (West, Dovidio, & Pearson, 2014). Therefore, White racial identity was coded as -1 and minority racial/ethnic statuses was coded as 1.

Standardizing the Continuous Variable

As recommended by Frazier et al. (2004), since the predictive variable, clients’ first OQ-

45.2-TA scores, was continuous, it was standardized by using z scores. The standardized OQ-

45.2-TA scores had a mean of 0 and a standard deviation of 1, which made it easier to interpret moderator effects by using the mean and ±1 standard deviation from the mean (Frazier et al.,

2004).

Creating the Product Term

To form product terms, the predictor (TA) was multiplied with the moderator (Race;

Frazier et al., 2004). There was only one interaction term because there were two levels of clients’ racial/ethnic status (i.e. White and REM; Frazier et al., 2004).

Structuring the Equation

To structure a multiple regression equation and test the moderation effect in this study, variables were entered into the hierarchical regression equation through three steps (Frazier et al., 2004). In Step 1, the predictor (TA) and controlled variable (OQ1 Total) were first entered into the regression model. In Step 2, the moderator (Race) was entered after the predictor and control variables. In Step 3, the product term (TA × Race) was entered into the regression equation.

Interpreting the Effects of the Predictor and Moderator Variables

The regression coefficients of the predictor (TA) and moderator (Race) represented their unique and conditional relations with the outcome variable (i.e. treatment outcome; Frazier et al.,

2004). More specifically, the regression coefficient of the therapeutic alliance represented the regression of the treatment outcome on the therapeutic alliance when clients’ racial/ethnic status was coded 0. Similarly, the regression coefficient of clients’ racial/ethnic status represented the regression of the treatment outcome on clients’ racial/ethnic status when the therapeutic alliance was coded 0.

Testing the Significance of the Moderator Effect

The moderator effect was tested with omnibus F test reflecting stepwise change when the product term (TA × Race) was entered into the regression equation (Frazier et al., 2004). If the omnibus F test and the single degree of freedom t test related to the product term (TA × Race) were both significant, then the moderation effect would be indicated.

Interpreting the Significant Moderator Effect

If a significant moderator effect existed, it could be plotted as a figure (Frazier et al.,

2004). The predicted values of the treatment outcome would be calculated for clients who had a high versus low therapeutic alliance (the predictor), as well as clients who were White versus

REM status (the moderator). Then, the predicted values could be plotted on a chart to visualize the moderator effect. Moreover, to provide more information about the relationship between the therapeutic alliance and treatment outcome for different racial groups, the researcher also tested

(a) the significance of the slope of simple regression between the therapeutic alliance and treatment outcome for REM clients and (b) the significance of the slope of simple regression between the therapeutic alliance and treatment outcome for White clients. Confidence intervals for these two slopes would also be calculated and examined (Frazier et al., 2004).

Chapter IV Results

Hypothesis 1: Difference in the Therapeutic Alliance

An independent-samples t-test was conducted to test whether the therapeutic alliance reported by REM clients was significantly lower than that reported by White clients. The test was significant, t(438) = 3.02, p < .01. TA rated by REM clients had lower means (M = 50.05,

SD = 4.75) than TA scores rated by White clients (M = 51.34, SD = 3.82). The 95% confidence interval for the difference in means was wide and it ranged from .045 to 2.13. Effect size estimate of the difference in TA between White and REM clients, expressed as g, was medium (g

= .31).

A one-way analysis of variance (ANOVA) was conducted to examine the differences in the therapeutic alliance among each racial group: African American (M = 49.47), Asian and

Pacific Islander (M = 49.03), Caucasian (M = 51.34), Latina/Latino (M = 51.19), and Multiracial

(M = 50.68). The ANOVA was significant, F(4, 432) = 3.86, p = .004. Post hoc comparisons were conducted using Tukey HSD test to evaluate the pairwise differences among the means.

There was significant mean difference in the therapeutic alliance between Caucasian and Asian and Pacific Islander. There was no significant difference in the therapeutic alliance among other pairs of racial groups. The result signified that the difference in the therapeutic alliance between

White and REM clients may be partially driven by the difference between White and Asian

American clients.

Hypothesis 2: Difference in Treatment Outcome

First, preliminary analysis was performed to compare treatment outcome between White and REM clients with regard to the percentage of clients who made reliable change. Clients’ last

OQ-45.2 scores were subtracted from the first OQ-45.2 score to measure progress of treatment in

the current sample and a difference of 14 points signified “Reliable Change” (Lambert, 2015;

Lambert et al., 2015). For the entire sample, the average change in scores was -15.14 points (SD

= 21.49), meaning that the average client had 15.14 points of decrease in OQ-45.2 score by the end of treatment. For White clients, the average outcome of subtraction was -14.23 points (SD =

21.57). About half of White clients (N = 153, 49.7%) showed a decrease in OQ-45.2 score that was equal to or more than 14 points, indicating significant improvement. For REM clients, the average outcome of subtraction was -16.32 points (SD = 22.05). About half of REM clients (N =

70, 53%) showed significant improvement and a decrease in OQ-45.2 score that was equal to or more than 14 points.

Second, an independent-samples t-test was performed to test that there was a significant difference in treatment outcome (i.e., OQ2 Total - OQ1 Total) between White and REM clients.

The test was not significant, t(438) = .76, p > .05, indicating that treatment outcome of REM clients (M = -16.32, SD = 22.05) was not significantly different from that of White clients (M = -

14.23, SD = 21.57). The 95% confidence interval for the difference in means ranged from -2.71 to 6.08. Effect size estimate of the difference in OQ-45.2 between White and REM clients, expressed as g, was small (g = .08).

Third, a one-way analysis of variance (ANOVA) was conducted to examine the differences in treatment outcome, calculated by subtracting OQ2 by OQ1, among each racial group: African American (M = -16.47), Asian and Pacific Islander (M = -17.79), Caucasian (M =

-14.63), Latina/Latino (M = -16.48), and Multiracial (M = -13.68). The ANOVA was not significant.

Hypothesis 3: Clients’ Race/Ethnicity as A Moderator

To test the hypotheses that clients’ race is a moderator between the therapeutic alliance and total scores of treatment outcome, as well as its three subscales (i.e., subjective discomfort, interpersonal relationships, social role performance), hierarchical linear regression analyses were conducted.

Examination of The Assumptions of Multiple Regression

Scatterplots and correlation analysis were used to check linearity and multicollinearity of all main variables (Tabachnick & Fidell, 2012). Scatterplots suggested linear relationships and low correlations between all pairs of variables. The correlation coefficients of the pertinent measures are displayed in Table 1. The histogram and residual plots of the predicted variable OQ2 Total suggested that the assumptions of normality, linearity, homoscedasticity, and independence of errors were met (Tabachnick & Fidell, 2012). Diagnostic tools showed that all of the tolerance values were greater than .20, variance inflation factor (VIF) less than 4, and condition index less than 30, which suggested no issues with multicollinearity (Tabachnick & Fidell, 2012).

Hierarchical Linear Regression Analysis

Predictive variable (TA) and controlled variable (OQ1 Total) were standardized using z scores in order to create a mean of 0 as well as reduce multicollinearity (Frazier et al., 2004).

Frazier et al. (2004) and West et al. (1996) suggested that effects coding should be applied on binary moderators (e.g., race) because, when White racial status is coded as -1, REM is coded as

1, with standardized TA having a mean of 0, the first order effects of Race and TA are average effects. Hence, effects coding was applied to the moderator. The product term was created by multiplying coded Race with the z score of TA.

At step 1 of this hierarchical linear regression, standardized TA and OQ1 were entered as a predictive and controlled variable, respectively. They accounted for a significant amount of

variance in treatment outcome OQ2 Total, R2 = .373, F(2,437) = 129.98, p < .01. TA was significantly and negatively associated with OQ2 Total (B = -3.81, SE = 0.94, p < .01). At step 2, clients’ race was entered as a moderator. The model appeared to be significant, R2 = .376,

F(2,436) = 87.66, p < .01, but race was not significantly associated with OQ2 Total. R2 change was not significant (ΔR2 = .003, p = .134). At step 3, the product term Race × TA was entered.

Again, the model appeared to be significant, R2 = .377, F(4,435) = 65.82, p < .01, but the interaction term Race × TA was not significantly associated with OQ2 Total. R2 change was not significant (ΔR2 = .001, p = .452). The results suggested that clients’ race was not a moderator between TA and treatment outcome (see Table 2.).

The same hierarchical linear regression analyses were also performed separately on the three subscales of OQ-45.2: OQ2 Subjective Discomfort Subscale (OQ2 SD), OQ2 Interpersonal

Relationships Subscale (OQ2 IR), OQ2 Social Role Performance Subscale (OQ2 SR). In predicting OQ2 SD (outcome variable) using OQ1 SD (covariate), TA, Race, and Race × TA

(predictors), the model was significant, R2 = .372, F(4,435) = 64.49, p < .01. TA was a significant predictor of OQ2 SD (B = -2.68, SE = 0.78, p < .01), but Race and Race × TA were not significant predictors (see Table 3.). In predicting OQ2 IR (outcome variable) using OQ1 IR

(covariate), TA, Race, and Race × TA (predictors), the model was significant, R2 = .396, F(4,435)

= 71.38, p < .01. TA was a significant predictor of OQ2 IR (B = -1.20, SE = 0.34, p < .01), but

Race and Race × TA were not significant predictors (see Table 4.). Lastly, in predicting OQ2 SR

(outcome variable) using OQ1 SR (covariate), TA, Race, and Race × TA (predictors), the model was significant, R2 = .253, F(4,435) = 36.75, p < .01. TA was a significant predictor of OQ2 SR

(B = -.81, SE = 0.25, p < .01), but Race and Race × TA were not significant predictors (see Table

5.).

In conclusion, an independent-samples t-test suggested that REM clients reported a significantly lower therapeutic alliance than White clients, which supported Hypothesis 1. A second independent-samples t-test indicated that there was no significant difference in treatment outcome between REM and White clients, which supported Hypothesis 2. A hierarchical linear regression analysis did not indicate the clients’ race/ethnicity moderated the alliance-outcome relationship, which did not support Hypothesis 3. Clients’ race/ethnicity was not a moderator between the therapeutic alliance and the OQ-45.2 Subjective Discomfort Subscale, the therapeutic alliance and the OQ-45.2 Interpersonal Relationships Subscale, and the therapeutic alliance and the OQ-45.2 Social Role Performance Subscale.

Chapter V Discussion

The current study is significant as it is the first known study to examine clients’ race/ethnicity as a moderator of the relationship between the therapeutic alliance and treatment outcome. In terms of providing clients with effective treatment, research indicates that the therapeutic alliance is among the most significant predictors of positive treatment outcome

(Flückiger et al., 2019, 2020; Lambert & Barley, 2001; Norcross, 2011). There is, however, a limitation in the psychotherapy research as most of these studies were conducted with predominantly White client samples. Hence, the alliance-outcome relationship remains largely unexamined for REM clients (Flückiger et al., 2018; Vasquez, 2007). An examination of whether clients’ race/ethnicity modifies the alliance-outcome relationship may be particularly important since REM clients may experience psychotherapy differently than White clients

(Comas-Díaz, 2006; Hook et al., 2016; Whaley, 2001). Findings from the current study contribute to the extant literature in three important ways: first, the findings provide insight into whether REM and White clients differ in terms of their experience of the therapeutic alliance; second, the findings also contribute to our understanding of whether REM as compared to White clients report differences in terms of treatment outcome; and, lastly, this study explores whether clients’ race/ethnicity moderates the alliance-outcome relationship. In this study, it was hypothesized that (a) the therapeutic alliance scores reported by REM clients would be significantly lower than those reported by White clients (Hypothesis 1), (b) there would be no significant difference in treatment outcome between White and REM clients (Hypothesis 2), and

(c) clients’ racial/ethnic status would moderate the alliance-outcome relationship in which the relationship is weaker for REM clients (Hypothesis 3). Results of the study support the first two hypotheses, but they did not support the third hypothesis. In this chapter, findings related to each

hypothesis are discussed within the context of previous research. In addition, the discussion includes an exploration of practical implications of the findings and concludes with an overview of directions for future research.

First, results from this study support Hypothesis 1 and indicate that REM clients rated the therapeutic alliance significantly lower than White clients. This finding is consistent with other research in which REM clients reported a lower alliance with their therapist than White clients

(Eliacin et al., 2018; Morales et al., 2018; Walling et al., 2012); however, it should be noted that

Taft et al. (2004) did not find a difference. The effect size difference for this study is g = .31, which many would consider substantial. Even using Cohen’s (1988) system, the effect size would be considered moderate. Results from the current study provide further support to the results found by Walling et al. They found a significant interaction between the therapeutic alliance and clients’ race/ethnicity, such that the therapeutic alliance reported by White clients steadily increased as treatment progressed, while the therapeutic alliance reported by REM clients did not show this pattern of increases. The lack of growth in the therapeutic alliance reported by REM clients indicated that REM clients may experience a more tenuous therapeutic alliance compared to White clients, which was consistent with findings in the current study. In addition, Walling et al. only examined differences in trajectories of the two groups and they did not examine differences in the therapeutic alliance. The current study expands on their finding by providing direct evidence that the therapeutic alliance reported by REM clients is significantly lower than that reported by White clients.

Results from the current study also validates the findings of Eliacin et al. (2018), in which the therapeutic alliance was compared between White and African American veterans.

Eliacin et al. found that African American veterans reported a lower therapeutic alliance

compared to White veterans. The difference was significant even though both groups reported a relatively high therapeutic alliance (i.e., the ceiling effect). The current study finds similar results in the college and community population. Moreover, the current study compares the therapeutic alliance between White and REM clients, instead of one specific racial/ethnic minority group (e.g., African American). The finding from this study suggests that, despite the cultural diversity within REM client populations, there is commonality in their experience in psychotherapy that renders their experience of a weaker therapeutic alliance compared to White clients (Constantine, 2007; Gelso & Carter, 1994; Taft et al., 2001).

REM clients’ negative expectations about mental health treatment (Sussman et al., 1987) and cultural mistrust (Davis et al., 2015; Terrell & Terrell, 1984; Whaley, 2001) may contribute to our understanding of why REM clients reported a weaker alliance with their therapist.

Interestingly, ANOVA and post hoc analyses indicated that the difference in the therapeutic alliance between White and REM clients was partially driven by the difference between White and Asian American clients. Research indicated that Asian American clients’ cultural context has a significant impact on the therapeutic relationship. Their high context communication style and cultural-specific values (e.g., emotional self-control, avoidance of shame, filial piety, hierarchical relationships) may make them less engaged in the therapeutic relationship if therapists do not consider Asian American clients’ needs sensitively (Hynes, 2019; Oba, 2017). Moreover, therapists may not provide REM clients with an explanation of their problems that is culturally meaningful, which could also diminish the therapeutic alliance reported by REM clients (Benish et al., 2011; Wampold, 2007). Wampold (2007) contended that an essential function of psychotherapy is to help the client create a new, adaptive, and actionable narrative of the clients’ struggles in place of the maladaptive explanation of the problems. Numerous studies (e.g.,

Benish et al., 2011; Frank & Frank, 1991; Vasquez, 2007; Wampold, 2007) have found that developing a culturally meaningful explanation of a clients’ problems, or cultural adaptions of the illness myth, is crucial for achieving a positive therapeutic alliance. For example, a racial minority student matriculating at a predominantly White institute may initially present with symptoms of anxiety. An assessment of the student’s cultural experience could reveal that the symptoms of anxiety are typically triggered by the feelings of exclusion and experiences of microaggression throughout the student’s lifetime, which have been exacerbated since the student came to a predominantly White college campus. A therapist could offer the student an insight that the student’s anxiety may be a trauma response based on experiences of racial discrimination, which is culturally meaningful and validating to the student and may strengthen the therapeutic relationship (Comas-Díaz, 2016). Because of the Eurocentric biases embedded in mainstream psychotherapies, many therapists may not be able to provide culturally meaningful explanations to REM clients’ issues (Bryant-Davis, 2007; Carter, 2007; Comas-Díaz et al., 2019;

Helms et al., 2010). The lack of culturally meaningful explanations may contribute to the weaker therapeutic alliance reported by REM clients compared to White clients in this study.

The second noteworthy finding of the study is that there was no significant difference in reported treatment outcome between White and REM clients, which supports the second hypothesis. This promising finding indicates that that REM clients who engage in psychotherapy benefit as much from it as White clients. While there was no significant difference, REM clients’ mean score of the outcome measure (M = -16.32) actually showed that they improved slightly more than White clients (M = -14.23). Multiple studies support the finding that, when psychotherapy outcome is compared between White and REM clients, the outcome of the two groups does not differ (Drinane et al., 2016; Hayes et al., 2015, 2016; Imel et al., 2011; Ünlü

Ince et al., 2014). The same finding is consistent with research conducted in college counseling settings (Drinane et al., 2016; Hayes et al., 2015, 2016; Lambert et al., 2006), which is relevant to the current study because a large percent of the current sample were college students. For example, in a sample from a college counseling center, Hayes et al. (2015) measured treatment outcome using a measure that was an earlier version of the same outcome measure, OQ-45, used in the current study. They did not find a significant difference in treatment outcome between

White and REM clients. Similar results were also replicated by Hayes et al., (2016) who used a much larger sample. It is worth noting that, whereas the aforementioned studies (e.g., Drinane et al., 2016; Hayes et al., 2016; Imel et al., 2011) emphasized outcome differences at the therapist level, indicating that some therapists can work more effectively with REM clients than others, their studies found a lack of difference in treatment outcome between REM and White clients generally. Taken together, results from the current study show additional evidence that REM clients who seek psychotherapy reap the benefit as much as White clients.

Given that REM clients are at risk of greater mental health challenges (APA, 2017; Hall et al., 2020; U.S. Surgeon General, 2001), it is remarkable that REM clients in the current study achieved the same positive outcome in psychotherapy as White clients. One possible reason that may explain this lack of difference could be that REM clients drop out of treatment more frequently than White clients (e.g., Owen et al., 2017, 2012; Wierzbicki & Pekarik, 1993).

Measuring treatment outcome of only REM clients who persisted in treatment may cloud an actual difference in outcome between REM and White clients. Research has found consistently that REM clients drop out of treatment at a higher rate than White clients (Cooper & Conklin,

2015; Swift & Greenberg, 2012, 2015). Wierzbicki and Pekarik (1993) conducted a meta- analysis of 125 studies on clients who dropped out of psychotherapy and found a mean effect

size of .23, suggesting a significant relationship between race and dropout rate. Many REM clients may drop out of psychotherapy early on due to cultural mistrust and the experience of microaggression (Constantine, 2007; Davis et al., 2015; Wong et al., 2007). These same phenomena might have occurred in the current study. If this was the case, data in the current study might only represent REM clients who were resilient enough to continuously engage in psychotherapy. Therefore, the results of the current study suggest that REM clients who persist in psychotherapy benefit from it as much as White clients do.

Third, the results from this study did not support Hypothesis 3 that clients’ racial/ethnic status moderates the alliance-outcome relationship, which suggests that the alliance-outcome relationship did not differ between REM and White clients. Hence, the results indicated that clients’ race/ethnicity is not a moderator of the alliance-outcome relationship, despite the findings that REM clients reported a weaker therapeutic alliance scores than White clients.

One previous study somewhat contradicted the results of the current study. In a meta- analysis, Flückiger et al. (2013) examined the percentage of REM clients within a sample as a moderator between the alliance-outcome relationship. They found that higher percentages of

REM clients in a sample were associated with weaker alliance-outcome relationships, which indicated that the more REM clients included in a sample, the weaker the alliance-outcome relationship. The current study directly examined clients’ race/ethnicity as a moderator of the alliance-outcome relationship in one sample, which differs from testing the percentage of REM clients as a moderator in Flückiger et al.’s meta-analysis.

Considering the mixed findings from Flückiger et al.'s (2013) and the current study, one may speculate whether clients’ race/ethnicity is a moderator of the alliance-outcome relationship.

It is possible that clients’ race/ethnicity does indeed moderate the alliance-outcome relationship

and the reason why the moderation effect was not found is because of statistical and methodological issues. First, the sample size and the power of regression analysis may not have been large enough to detect the moderation effect. Although a priori analysis of power showed that the current sample of 440 was sufficient, the unequal sizes between White (N = 330) and

REM (N =132) groups could have hindered the power of the statistical analyses (Frazier et al.,

2004).

A second possible reason why the moderation effect was not detected may be related to when the therapeutic alliance was assessed during the course of treatment. In the clinic where data was collected, the therapeutic alliance measure was not administered after every session and only the first therapeutic alliance score of each client was used in data analyses. One score may not be representative of the overall quality of the therapeutic alliance between a client and therapist as the alliance fluctuates throughout the course of treatment (Walling et al., 2012). If the therapeutic alliance was measured more thoroughly (e.g., using an average of multiple TA scores measured throughout treatment), a moderation effect clients’ race/ethnicity might have been detected.

Scholars have also suggested that moderators may be difficult to find if the relationship between a predictor and outcome variable is consistently robust (Baron & Kenny, 1986), which was the case for the alliance-outcome relationship in this study. Therefore, if clients’ race/ethnicity does indeed moderate the alliance-outcome relationship, it may require a larger sample and higher statistical power to detect such an effect. Moreover, the moderation effect may be more difficult to find in nonexperimental studies, such as the current study, as compared to experimental designs (McClelland & Judd, 1993). A further discussion of the limitations of this study is elaborated below.

On the other hand, it is possible that the findings reflect that clients’ race/ethnicity alone does not moderate the alliance-outcome relationship. It may be that there are many other intersecting factors that influence the alliance-outcome relationship for REM clients in psychotherapy, and, therefore, using only the crude measure of self-reported race or ethnicity does not capture the cultural differences. Heppner et al. (2007) asserted that proximal variables

(e.g., level of racial identity development) may be better measures of cultural differences than distal variables (e.g., race). While client’s racial/ethnic identities are significant factors to consider in psychotherapy (Comas-Díaz, 2006; Vasquez, 2007), proximal cultural constructs may provide nuanced information about how culture makes a difference in various situations

(Heppner et al., 2007). The current study did not include data on proximal cultural factors, such as level of racial identity development (e.g., Cross, 1995; Helms, 1995; Kim, 2012; Ruiz, 1990;

S. Sue & D. W. Sue, 1971), level of acculturation (e.g., Akhtar, 2010; Kim et al., 1999), or experience of racial trauma (Bryant-Davis, 2007; Carter, 2007; Helms et al., 2010). The way that clients’ cultural identities and experience affect the psychotherapeutic process may be complex, so clients’ race/ethnicity alone may not moderate the alliance-outcome relationship.

Another reason why clients’ race/ethnicity does not moderate the alliance-outcome relationship may be related to therapist factors (e.g., therapists’ multicultural competence), which are more likely to be moderators of this relationship. In general, client factors (e.g., clients’ race/ethnicity) have less influence on the alliance-outcome relationship as compared to therapist factors (Del Re et al., 2012). Several studies have found a close relationship between multicultural competence and the therapeutic alliance and treatment outcomes (Fuertes et al.,

2006; Owen et al., 2011). A meta-analysis of 18 studies on multicultural competence found that the correlation between multicultural competence and outcome was .29 (Tao et al., 2015). The

current study did not include data on therapist factors such as multicultural competence, which might be a moderator of the alliance-outcome relationship and overshadow the influence of clients’ race/ethnicity.

In summary, findings of the study provided evidence regarding the three hypotheses.

First, the results support the first hypothesis that REM clients would report lower alliance scores than White clients. This result is consistent with findings that REM clients may report a weaker therapeutic alliance in psychotherapy than White clients, possibly due to their negative expectations of treatment, cultural mistrust, experience of microaggression in session, and the lack of culturally meaningful explanation to their problems in psychotherapy (Benish et al.,

2011; Davis et al., 2015; Terrell & Terrell, 1984; Whaley, 2001). Second, the results support findings from previous literature and indicate that there is no significant difference in treatment outcome between White and REM client (Hypothesis 2). The good news is, the finding suggests that REM clients who persist in psychotherapy may benefit as much as White clients do.

However, the lack of difference in treatment outcome may be because there are a large number of

REM clients who dropped out of treatment and therefore were not included in the sample. Third, the results showed that client’s racial/ethnic status does not moderate the alliance-outcome relationship (Hypothesis 3). It is possible that a lack of statistical power in the current data may have contributed to an existing moderation effect being undetected. On the other hand, other process variables (e.g., clients’ racial identity development, therapists’ multicultural competence) may be stronger moderators of the alliance-outcome relationship than clients’ race/ethnicity.

Limitations

Although this study provides useful information related to effective psychotherapy with

REM clients, there are a number of limitations in this study that should be noted. First, the

sample size, particularly the number of REM clients, may have been too small to generate enough statistical power to detect the moderation effect of client’s race/ethnicity on the alliance- outcome relationship. Statistical power is essential in nonexperimental studies in detecting interaction effects (McClelland & Judd, 1993). The sample sizes of White (N = 330) and REM

(N =132) clients were unequal, which could have also decreased the power of the statistical analyses. Frazier et al. (2004) concluded that when there are two groups in the categorial variable (e.g., race), “power decreases as the sample size proportions vary from .50/.50, regardless of the total sample size” (p. 118). Although the current study included client information gathered from a Midwestern university training clinic for more than four years, the number of REM clients (i.e. 132) was somewhat small and possibly limited the analyses. Future researchers are encouraged to use samples with a higher percentage of REM clients.

A second possible limitation to this study concerns the measure of the therapeutic alliance. While the OQ-45.2-TA is a measure that is commonly used in clinical settings

(Lambert et al., 2004), little evidence has been gathered regarding its validity and reliability among REM client populations. Meta-analysis of studies on the therapeutic alliance (Flückiger et al., 2018) showed that, when the therapeutic alliance was measured for research purpose, the majority of the studies used California Psychotherapy Alliance Scale (CALPAS; Marmar et al.,

1986), Helping Alliance Questionnaire (HAQ; Alexander & Luborsky, 1986), Vanderbilt

Psychotherapy Process Scale (VPPS; Suh et al., 1986), and the Working Alliance Inventory

(WAI; Horvath & Greenberg, 1989). There tends to be more evidence on the validity and reliability of these measures, which makes them possibly more suitable for research purposes.

The therapeutic alliance measure used in this study may present issues such as coarseness (i.e. the 5-point Likert scale may not adequately capture the variance of the therapeutic alliance) and

a ceiling effect (i.e. the distribution of the therapeutic alliance scores tends to be negatively skewed), which could also reduce statistical power in detecting interaction effects (Russell &

Bobko, 1992).

Moreover, in the clinic where the data were collected, therapists were instructed to administer the therapeutic alliance measure every four sessions, but it appears that some therapists may have not followed this instruction closely. This created inconsistency in when the therapeutic alliance was assessed for each client and, therefore, added confounding variance in the data. Hence, future researchers are encouraged to use a measure of the alliance that is suitable for research purpose (e.g., WAI) and to ensure that therapists administer a measure of the therapeutic alliance regularly and consistently.

A third limitation of the study concerns therapist variables and the lack of information available concerning the therapists. The data did not contain information about which client was treated by which therapist, so the researcher was not able to examine racial differences in the therapeutic alliance or treatment outcome within a therapist’s caseload (i.e., the therapist effect).

Also, therapists’ race/ethnicity status was not collected, so the researcher did not have the information regarding whether a REM client is matched with their therapist based on race. Some research suggested that therapist-client’s racial matching could impact the alliance-outcome relationship (Cabral & Smith, 2011). Therefore, data on therapist-client’s racial matching could be collected and added to the data analyses as a controlled variable.

The fourth limitation of the study concerns proximal variables that measure clients’ cultural experiences (e.g., identify development, level of acculturation, experience of racial trauma), which were not assessed in the current study. In addition, the study did not include culturally relevant process variables from the client’s perspective (e.g., cultural mistrust,

microaggression in psychotherapy) that may be influential in the treatment of REM clients. Data on therapists’ multicultural competence and multicultural humility were also not available.

Measuring and including these variables in the design of the study may provide a more nuanced view on how cultural factors affect the experience of REM clients in psychotherapy.

Practical Implications

Findings of the current study generate important practical implications for therapists working with REM clients. Since REM clients reported lower therapeutic alliance scores than

White clients, therapists are urged to find effective ways to build the therapeutic alliance with

REM clients. Moreover, therapists should find ways to build the therapeutic alliance with REM clients early and effectively so that they can be retained in treatment. A meta-analysis found that the strength of the therapeutic alliance is influenced more by therapists’ contribution to the relationship as compared to clients’ (Del Re et al., 2012), which suggests that therapists are the ones most accountable for the quality of the therapeutic alliance. Thus, therapists should seek continuing multicultural training that focuses on effective ways to build a therapeutic alliance with REM. Literature on microaggression in psychotherapy, multicultural competence, cultural humility, and racial trauma may provide valuable guidance for therapists on how to work effectively with REM clients.

In working with REM clients, therapists should, first and foremost, eliminate casting microaggressions on REM clients. Research has shown that clients’ experiences of microaggression in psychotherapy create cultural ruptures in the therapeutic relationship (Owen et al., 2011) and weakens the therapeutic alliance (e.g., Constantine, 2007; Hook et al., 2016;

Pope-Davis et al., 2002). D. W. Sue et al. (2007) provide examples of microaggressions in clinical practice that should be recognized and avoided by therapists. For example, a White

therapist may intend to normalize a client of color’s account of racial discrimination by saying,

“We all have difficult experiences in life.” This statement, however, may actually be dismissive, hurtful, and even infuriating to the client as it implies color blindness and a denial of racial injustice that permeates in the fabric of the U.S. society (Comas-Díaz, 2000). Interested therapists can also refer to D. W. Sue et al. (2019) on microintervention strategies for REM individuals, White allies, and bystanders.

Moreover, the findings from this study encourage therapists to provide culturally sensitive treatment in order to strengthen the therapeutic alliance with REM clients. Writings on multicultural competence and cultural humility may provide relevant guidance on culturally sensitive treatment (Owen et al., 2011, 203, 2017; D. W. Sue et al., 1982, 1992). Therapists may begin gaining multicultural awareness by understanding one’s own cultural background and biases. For example, White therapists should engage in multicultural education and reflect on the Eurocentric biases intrinsic to mainstream therapy (e.g., regarding independence, self- actualization, and setting clear interpersonal boundaries as good and necessary; APA, 2017;

Comas-Díaz, 2006; D. W. Sue et al., 1992).

The second aspect of providing culturally sensitive treatment is to gain knowledge about

REM clients’ unique cultural experiences, both with regard to their racial identities (e.g., Asian

American) and the intersectionality of multiple identities (e.g., Asian American queer woman;

Bowleg, 2008). Therapists should remain current on ethnic minority research, seek continuing education, and engage in dialogues with culturally diverse individuals in one’s personal and professional networks (APA, 2017a).

Thirdly, therapists need to gain skills to provide culturally sensitive treatment. For example, White therapists should recognize that REM clients may feel uncomfortable with

discussing their racial experiences (e.g., discrimination, microaggression) and associated emotions (e.g., pain, anger, helplessness) with them due to cultural mistrust. From the beginning of treatment, therapists may express cultural humility by conveying respect, lack of superiority, and attunement to client’s most salient cultural experiences (Hook et al., 2017a). Therapists’ cultural humility may help REM clients feel safe and validated and has been found to contribute to a positive therapeutic alliance and client’s estimate of improvement (Hook et al., 2013; Owen et al., 2016). When a REM client does bring up painful and racialized experiences to a White therapist, the therapist may express earnest appreciation and invite the client to share more about these experiences. White therapists should also take time to reflect on their racially privileged experiences and work through possible difficult emotions (e.g., shock, guilt, and shame) associated with the White identity (DiAngelo, 2011). This typically affords White therapists with greater cultural comfort, a capacity to genuinely empathize with REM clients’ racialized experience and to create a space for the processing of painful emotions. Owen (2013) coined the term cultural comfort as therapists’ openness and willingness to initiate conversations about clients’ cultural heritage, and, in turn, to allow clients’ experience to enrich their own appreciation for cultural diversity. A greater level of cultural comfort has been found to lead to less unilateral termination by REM clients (Owen et al., 2017). When a REM client can develop trust for a White therapist and receive validation about their racial discrimination, an emotionally corrective experience may occur, which strengthens the REM client’s alliance with the therapist

(Fuertes et al., 2006; Hook et al., 2017a; Owen, Tao, et al., 2011).

Furthermore in psychotherapy, therapists should be equipped to address race-related victimization and trauma and further build the therapeutic alliance with REM clients (Alvarez et al., 2016b; Comas-Díaz et al., 2019). Comas-Díaz (2016) provided a race-informed approach to

heal racial wounds by situating racial trauma in the context of colonization. Racial trauma is the psychological pain that arises from people of color’s internalization of colonial cultural values

(e.g., Euro-American values) and subordination to the oppresserd (e.g., White supremacy; David

& Okazaki, 2006; Fanon, 2008). Therefore, to heal racial trauma entails facilitating REM clients’ psychological decolonization in the context of a racist environment (Comas-Díaz, 2016).

A race-informed therapist would first conduct an assessment of the client’s historical, generational, and continuing racial trauma. The therapist may assess the severity of the client’s racial wounds by listening to the client’s stories, as well as by using measures such as the

Schedule of Racist Events (Landrine & Klonoff, 1996) and Race-Based Traumatic Stress

Symptom Scale (Carter et al., 2013). In the second step, the therapist would help the client desensitize the traumatic reactions by utilizing behavioral techniques (e.g., visualization, progressive muscle relaxation, EMDR) and indigenous healing approaches. This step is necessary as it helps the client regulate traumatic reactions and be prepared for the reprocessing of traumatic experiences. Then, the therapist would guide the client to replace negative cognitions with positive cognitions. For example, Comas-Díaz (2007) discussed helping a

Latina who felt inadequate due to race-related stress by using a Spanish proverb, “El que no sabe es como el que no ve” (“She or he who doesn’t know is like she or he who doesn’t see”). In this step, the therapist provides psychoeducation about racism, which would foster the client’s development of critical consciousness (Freire, 1970), and, ultimately, a sense of empowerment.

In the fourth step, the therapist would facilitate the client’s psychological decolonization by contextualizing the client’s traumatic experiences in the oppressive realities, normalizing client’s survival strategies as a response to race-based trauma, and differentiating the functional from the dysfunctional responses. The therapist would continue to nurture the client’s critical

consciousness and discuss questions such as “Who benefits from racism? Against whom is racism directed? In favor of what does racism exist? To what end?” (p. 260; Comas-Díaz, 2016).

Lastly, the therapist would encourage the client to move toward social action as a crucial step of racial healing. The therapist and client would discuss various approaches to engage in social action, such as providing testimony, community engagement, advocacy, spiritual/religious activities, and sociopolitical involvements. Comas-Díaz’s approach to heal racial trauma provides a roadmap for therapists to centralize REM clients’ racial experiences in psychotherapy.

During this process, trust in the therapeutic relationship is the catalyst of healing and empowerment (Comas-Díaz, 2016). Results from the current study urge therapists to provide culturally sensitive and race-informed treatment, which may lead to meaningful growth in the therapeutic alliance and treatment outcome.

Directions for Future Research

The findings from this study reflect some important directions for future research. First, as discussed earlier, there are few research studies focusing on the alliance-outcome relationship for REM clients. Furthermore, the findings are mixed with regard to whether the alliance- outcome relationship is as strong for REM clients as it is for White clients. Therefore, more research is needed to examine the therapeutic alliance and its potency in predicting treatment outcome in psychotherapy among various REM client groups, such as African American, Latinx

American, Asian American, and Native American.

Second, more research is needed to understand the relationships among culturally- relevant process variables (e.g., multicultural competence, cultural humility, microaggression in session, cultural mistrust, cultural adaptions of the illness myth), the therapeutic alliance, and treatment outcome in psychotherapy for REM clients. For example, future studies could address

questions such as: Does therapist’s cultural humility mediate the alliance-outcome relationship?

Does cultural mistrust moderate the alliance-outcome relationship? Does experience of microaggression in session moderate the alliance-outcome relationship?

Third, given the degree of diversity within the REM client population, more research is needed to understand different cultural groups’ experience in psychotherapy. Not only are there racial and ethnic differences within this population, REM individuals may hold other salient identities simultaneously with regard to gender, social economic status, sexual orientation, immigration status, level of acculturation, and location of residence. Future researchers should consider adapting an intersectionality lens (Cole, 2009) in order to better understand the experience of clients with intersecting cultural identities (e.g., undocumented South American immigrants, Asian American women, Black LGBTQ individuals).

Conclusion

Psychotherapy process-outcome research is a long-standing line of inquiry (Chambless et al., 2006; Lambert & Bergin, 2013; Norcross & Lambert, 2018), but research has primarily been with predominantly White samples, and REM clients’ experience in psychotherapy is still a relatively new area of research (Comas-Díaz, 2006; Flückiger et al., 2018; Rossello & Bernal,

1999). There are also studies indicating that REM clients face unique challenges in accessing and completing psychotherapy (Hall et al., 2020). In addition, REM clients may lack of trust in the therapeutic process and may have experienced microaggression by their therapists in psychotherapy (Constantine, 2007; Hook et al., 2016; D. W. Sue et al., 2007). Racial trauma may be at the core of REM clients’ mental health struggles (Alvarez et al., 2016b; Comas-Díaz et al., 2019), but therapists may not be equipped with the knowledge and skills to adequately address these issues. Therefore, REM clients’ experience in psychotherapy may be different

from White clients and it is crucial to understand what helps REM clients succeed in psychotherapy. Psychotherapy process-outcome research has shown that the therapeutic alliance is among the most important predictors of positive treatment outcome in predominantly White samples (e.g., Flückiger et al., 2018, 2020; Horvath et al., 2011; Norcross, 2011). Therefore, it is important to explore whether the alliance-outcome relationship is as robust in REM client population as it is for White clients

In this study, the researcher investigated differences between REM and White clients with regard to the therapeutic alliance, treatment outcome, and the alliance-outcome relationship. The study used archival data collected at a counseling training clinic at a Midwestern university, which included 308 Caucasian and 132 REM clients. The study found that, first, REM clients reported a weaker therapeutic alliance than White clients. Second, there was no significant difference in treatment outcome between White and REM clients. Third, client’s race/ethnicity did not moderate the alliance-outcome relationship, meaning that the strength of the relationship did not differ between White and REM clients. Analyses of the hypotheses and results were provided integrating previous literature. The findings of the study highlighted the unique experience of REM clients in psychotherapy and the importance of providing culturally sensitive and race-informed psychotherapy.

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Table 1. Correlations of the Main Measures.

TA OQ1 SD OQ1 IR OQ1 SR OQ1 Total OQ2 SD OQ2 IR OQ2 SR OQ2 Total

-.130** -- OQ1 SD p .006 -.154** .575** -- OQ1 IR p .001 .000 -.166** .649** .440** -- OQ1 SR p .000 .000 .000 -.163** .956** .753** .757** -- OQ1 Total p .001 .000 .000 .000 -.218** .590** .418** .400** .590** -- 91 OQ2 SD

p .000 .000 .000 .000 .000 -.235** .361** .610** .282** .469** .686** -- OQ2 IR p .000 .000 .000 .000 .000 .000 -.222** .362** .336** .479** .432** .703** .554** -- OQ2 SR p .000 .000 .000 .000 .000 .000 .000 -.248** .547** .503** .425** .591** .965** .826** .794** -- OQ2 Total p .000 .000 .000 .000 .000 .000 .000 .000 -.143** -.033 .021 .044 -.007 -.050 -.022 .002 -.038 Race p .003 .488 .654 .358 .885 .293 .641 .970 .427 Note. TA = Therapeutic alliance; OQ1 SD = The first administration of OQ-45.2 (subjective discomfort subscale), OQ1 IR = The first administration of OQ-45.2 (interpersonal relationships subscale), OQ1 SR = The first administration of OQ-45.2 (social role performance subscale), OQ1 Total = The first administration of OQ-45.2 (total score); OQ2 SD = The second administration of OQ-

45.2 (subjective discomfort subscale), OQ2 IR = The second administration of OQ-45.2 (interpersonal relationships subscale), OQ2 SR = The second administration of OQ-45.2 (social role performance subscale), OQ2 Total = The second administration of OQ-45.2 (total score); Race: 1 = REM, -1 = White. Most of the correlation analyses were conducted using Pearson’s correlation; however, since Race was a dichotomous variable, the correlations between Race and other variables were conducted using the point-biserial method. ** p < .01.

Table 2. Hierarchical Linear Regression Predicting OQ2 Total.

Measure R2 F Sig. ΔR2 B SE β t Sig. Step 1 .373** 129.977 .000 OQ1 Total (z score) 13.889 .942 .566** 14.738 .000

TA (z score) -3.812 .942 -.155** -4.045 .000 Step 2 .376** 87.655 .000 .003 OQ1 Total (z score) 13.846 .941 .564** 14.706 .000 TA (z score) -4.021 .951 -.164** -4.227 .000 Race -1.538 1.023 -.057 -1.503 .134 Step 3 .377** 65.817 .000 .001

OQ1 Total (z score) 13.842 .942 .564** 14.694 .000 TA (z score) -4.595 1.220 -.187** -3.766 .000

Race -1.470 1.027 -.055 -1.431 .153 TA × Race 1.442 1.918 .037 .752 .452 Note. Race: 1 = REM, -1 = White; TA = Therapeutic alliance; OQ1 Total = The first administration of OQ-45.2 (total score). ** p < .01.

Table 3. Hierarchical Linear Regression Predicting OQ2 Subjective Discomfort Subscale.

Measure R2 F Sig. ΔR2 B SE β t Sig. Step 1 .366** 127.743 .000 OQ1 SD (z score) 8.947 .600 .572** 14.922 .000

TA (z score) -2.247 .600 -.144** -3.747 .000 Step 2 .367** 85.973 .000 .001 OQ1 SD (z score) 8.903 .600 .596** 14.844 .000 TA (z score) -2.371 .606 -.152** -3.914 .000 Race -.903 .655 -.053 -1.380 .168 Step 3 .367** 64.494 .000 .000

OQ1 SD (z score) 8.909 .600 .569** 14.842 .000 TA (z score) -2.682 .777 -.171** -3.451 .001

Race -.866 .658 -.051 -1.317 .189 TA × Race .785 1.227 .032 .639 .523 Note. Race: 1 = REM, -1 = White; TA = Therapeutic alliance; OQ1 SD = The first administration of OQ-45.2 (subjective discomfort subscale). ** p < .01.

Table 4. Hierarchical Linear Regression Predicting OQ2 Interpersonal Relationships Subscale.

Measure R2 F Sig. ΔR2 B SE β t Sig. Step 1 .393** 141.237 .000 OQ1 IR (z score) 4.102 .263 .588** 15.578 .000

TA (z score) -1.01 .263 -.145** -3.836 .000 Step 2 .396** 95.189 .000 .003 OQ1 IR (z score) 4.102 .263 .588** 15.600 .000 TA (z score) -1.067 .266 -.153** -4.016 .000 Race -.431 .286 -.057 -1.507 .132 Step 3 .396** 71.377 .000 0

OQ1 IR (z score) 4.090 .264 .586** 15.499 .000 TA (z score) -1.197 .343 -.171** -3.487 .001

Race -.416 .287 -.055 -1.448 .148 TA × Race .322 .538 .029 .599 .549 Note. Race: 1 = REM, -1 = White; TA = Therapeutic alliance; OQ1 IR = The first administration of OQ-45.2 (interpersonal relationships subscale). ** p < .01.

Table 5. Hierarchical Linear Regression Predicting OQ2 Social Role Performance Subscale.

Measure R2 F Sig. ΔR2 B SE β t Sig. Step 1 .250** 72.948 .000 OQ1 SR (z score) 2.108 .195 .455** 10.821 .000

TA (z score) -.680 .195 -.147** -3.493 .001 Step 2 .252** 48.925 .000 .002 OQ1 SR (z score) 2.111 .195 .455** 10.838 .000 TA (z score) -.706 .197 -.152** -3.590 .000 Race -.202 .212 -.040 -.953 .341 Step 3 .253** 36.753 .000 .001

OQ1 SR (z score) 2.115 .195 .456** 10.845 .000 TA (z score) -.809 .252 -.174** -3.215 .001

Race -.189 .212 -.037 -.892 .373 TA × Race .261 .397 .036 .656 .512 Note. Race: 1 = REM, -1 = White; TA = Therapeutic alliance; OQ1 SR = The first administration of OQ-45.2 (social role performance subscale). ** p < .01.

Yue Li, Ph.D.  [email protected]

EDUCATION Doctor of Philosophy Indiana University Bloomington 08/2015 – 08/2020 Major: Counseling Psychology (APA-accredited) Minor: Organizational Behavior and Business Management Dissertation: Clients’ Race/Ethnicity as a Moderator of the Relationship between the Therapeutic Alliance and Treatment Outcome

Master of Science in Education Indiana University Bloomington 08/2015 – 12/2018 Learning and Developmental Sciences - Educational Psychology Track

Master of Science University at Albany, State University of New York 05/2013 – 12/2014 Mental Health Counseling (MPCAC-accredited)

Non-Degree Exchange University of Minnesota, Twin Cities 08/2010 – 12/2010 Psychology

Bachelor of Science Shanghai Normal University, Shanghai, China 09/2007 – 07/2011 Applied Psychology

HONORS AND AWARDS 2019 CEMRRAT2 2019 Student Travel Grant, Commission on Ethnic Minority Recruitment, Retention and Training in Psychology Task Force, American Psychological Association - Awarded to fund conference presentation for one of my first-authored studies: Perceived impact of globalization on Asian international students' post-graduation decision-making 2019 Paul Munger Award, Department of Counseling and Educational Psychology, Indiana University Bloomington - Awarded to recognize a student’s “outstanding character, service, and leadership” 2018 Trenthem Travel Award, Department of Counseling and Educational Psychology, Indiana University Bloomington 2018 APAGS Outstanding Division Award, American Psychological Association Graduate Students & Division 45 (Society of the Psychological Study of Culture, Ethnicity, and Race) 2017 Innovative Multicultural Programming Award, Commission on Multicultural Understanding, Indiana University Bloomington - Awarded to “Peer-versity --- Messages on Multiculturalism,” a peer-led multicultural panel discussion series that I and fellow graduate students created and implemented. 2015 Faculty Fellowship, Department of Counseling and Educational Psychology, Indiana University Bloomington - Guaranteed four years of full tuition remission and stipend during the doctoral program 2014 Research Travel Award, Graduate Student Association, University at Albany, SUNY 2013 Research Travel Award, Graduate Student Association, University at Albany, SUNY 2011 Honors Research Paper, Shanghai Normal University, Shanghai, China 2007 Shanghai Undergraduate Students Innovative Research Project Grant, Department of

Education, Shanghai, China

LANGUAGE SKILLS English: Fluent and trained to provide psychotherapy. Mandarin Chinese: Fluent and trained to provide psychotherapy.

PEER-REVIEWED PUBLICATIONS Journal Articles 9) Li, Y., Goodrich Mitts, N, & Whiston, S. C. (2019). Chinese international students’ expectations about career counseling. Journal of Career Development. 8) Wong, Y. J., Goodrich Mitts, N., Blackwell, N. Gabana, N., & Li, Y. (2017). Giving thanks together: A preliminary evaluation of the gratitude group program. Practice Innovations, 2(4), 243. 7) Whiston, S. C., Li, Y., Goodrich Mitts, N., & Wright, L. (2017). Effectiveness of career choice interventions: A meta-analytic replication and extension. Journal of Vocational Behavior, 100, 175-184. 6) Sheu, H., Liu Y., & Li, Y. (2016). Well-being of college students in China: Testing a modified social cognitive model. Journal of Career Assessment, 25(1), 144-158. 5) Dubovi, A. S., Li, Y., & Martin, J. L. (2015). Breaking the silence: Disordered eating and Big Five traits in college men. American Journal of Men’s Health, 10, 118-126.

Book Chapters 4) Wilkins-Yel, K. G., Chung, Y. B., Cheng, J., & Li, Y. (2018). Multicultural considerations in career assessment. In K. B. Stoltz & S. R. Barclay (Eds). A Comprehensive Guide to Career Assessment (7th ed.; pp. 59-73). Broken Arrow, OK: National Career Development Association. 3) Whiston, S. C., Goodrich Mitts, N., & Li, Y. (2018). Evaluation of career guidance programs. In H. Perera & J. Athanasou (Eds.). International Handbook of Career Guidance (2nd ed.). Springer Science & Business Media.

Newsletter Article 2) Li, Y. (2017). Identity development of Chinese feminists: Interviews of six Chinese feminists without western education. The Asian Pacific Women’s Connection.

Blog Article 1) Li, Y. (2019). The invisible types of gender discrimination in the workplace and how to address them. Arredondo Advisory Group. Retrieved at https://www.arredondoadvisorygroup.com/category/insights/

MANUSCRIPTS SUBMITTED OR IN PREPARATION Journal Article 4) Li, Y., Deng, K., Wilkins-Yel, K. G., Staton, E., & Lees, O. (in preparation). Perceived impact of globalization on Asian international students’ post-graduation decision making. 3) Wilkins-Yel, K. G., Gumbiner, L. M., Li, Y., Cheng, J., & Simpson, A. (in preparation). Understanding the factors that promote STEM interest and persistence among women of color in STEM. 2) Powless, M. D., Li, Y., Wilkins-Yel, K. G., Cheng, J., Lau, P. L., Wong, Y. J., & Biggers, M. (submitted for review). Men in STEM, join us: Recommendations on how male faculty can support female students' persistence.

Book Chapter 1) Li, Y. & Wong, Y. J. (submitted for review). Workplace sexism: A social dominance approach. In J. L. Chin, Y. E., Garcia, & A. Blume (Eds.). The Psychology of Inequity. Santa Barbara, CA: ABC- CLIO.

PEER-REVIEWED CONFERENCE PRESENTATIONS 17) Li, Y., Whiston, S., & Wong, Y. J. (2020, February). Clients’ race/ethnicity as a moderator of the relationship between the therapeutic alliance and treatment outcome. Poster presented at the 2020 Counseling Psychology Conference, New Orleans, LA. 16) Li, Y., Blackwell, N. M., Goodrich Mitts, N., Gabana, N. T., & Wong, Y. J. (2019, August). Evaluating the Gratitude Group Program - The First Known Group Program on Cultivating Gratitude. Symposium presented at the annual convention of the American Psychological Association, Chicago, IL. 15) Li, Y., Gumbiner, L. M., Wilkins-Yel, K. G., Cheng, J., & Simpson, A. (2018, August). Understanding the factors that promote STEM interest and persistence among women of color in STEM. Poster presented at the annual convention of the American Psychological Association, San Francisco, CA. 14) Li, Y., Wilkins-Yel, K. G., Powless, M. D., Lau, P. L., Cheng, J., Wong, Y. J., & Biggers, M. (2018, August). Men in STEM, join us: Recommendations on how male faculty can support female students' persistence. Poster presented at the annual convention of the American Psychological Association, San Francisco, CA. 13) Staton, E., Lees, O., Deng, K., Li, Y., & Wilkins-Yel, K. G. (2018, August). Perceived impact of globalization on Asian international students’ post-graduation decision making. Poster presented at the annual convention of the American Psychological Association, San Francisco, CA. 12) Xu, S., Richmond, C. E., Li, Y., & LaRue, G. (2018, August). Healing from Racial-Gendered Trauma. Poster to be presented at the 2018 American Psychological Association Annual Convention, San Francisco, CA. 11) Li, Y. & Whiston, S. (2017, August). Chinese international students' expectations about career counseling. Poster presented at the annual convention of the American Psychological Association, Washington, D.C. 10) Li, Y. (2017, August). Workplace sexism: A social dominance approach. Poster presented at the annual convention of the American Psychological Association, Washington, D.C. 9) Wong, Y. J., Li, Y., Goodrich Mitts, N., Blackwell, N. & Gabana, N. (2017, August). Giving thanks together: A gratitude group program. Skill-building session presented at the annual convention of the American Psychological Association, Washington, D.C. 8) Powless, M., Goorich Mitts, N., Blackwell, N., & Li., Y (2017, April). Applications of Positive Psychology to the Classroom, Counseling, and Outreach. Symposium presented at the 2017 Great Lakes Regional Counseling Psychology Conference, Muncie, IN. 7) Liu, J., Zounlome, N., & Li, Y. (2016, August). Exploring the Intersectionalities of Advisor Advisee Relationships in Psychology Doctoral Programs. Discussion hour presented at the annual convention of the American Psychological Association, Denver, CO. 6) Li, Y., Goodrich, G., & Cheng, J. (2016, April). Internationalized Psychology Training: Diverse Student Experiences in the U.S. Roundtable presented at the 2016 Great Lakes Regional Counseling Psychology Conference, Bloomington, IN. 5) Gabana, N., Blackwell, N., Goodrich, N., Li, Y., & Wong, Y. J. (2016, April). The Gratitude Group Program: Practicing Gratitude Together. Experiential activity presented at the 2016 Great Lakes Regional Counseling Psychology Conference, Bloomington, IN. 4) Buckner, L., Groth, G., Longo, L., Prout, J., & Li, Y. (2015, August). Health-risk behaviors among college students: Trends and implications for research and practice. Symposium presented at the

annual convention of the American Psychological Association, Toronto, ON. 3) Sheu, H., Liu, Y., & Li, Y. (2015, August). Well-being of college students in China: Differences by gender and locations. Poster presented at the annual conference of the American Psychological Association, Toronto, ON. 2) Li, Y., Dubovi, A. S., & Martin, J. L. (2014, August). Big Five Personality Traits and Disordered Eating Among Undergraduate Men. Poster presented at the annual conference of the American Psychological Association, Toronto, ON. 1) Hutman, H., Lerner, S., & Kotary, B., & Li, Y. (2014, June). Caught between two worlds: Understanding international students’ experiences and needs in clinical supervision. Roundtable session presented at the 10th International Interdisciplinary Conference on Clinical Supervision, Adelphi University, Garden City, NY.

PRE-DOCTORAL INTERNSHIP ((APA-ACCREDITED) Psychology Intern (08/2019 – 08/2020) Counseling Center, University of Illinois at Chicago, Chicago, IL Rotation: Marjorie Kovler Center, Heartland Alliance, Chicago, IL Supervisors: Jeanette Simon, Psy.D., Karen L. Maddi, Ph.D., Mirka Ivanovic, Psy.D., Dia Anjali Mason, Ph.D., Kurt Stevens, Psy.D., Cynthia Langtiw, Psy.D., Johanna Strokoff, Ph.D. ⬧ Provide brief (20 sessions) and long-term (weekly sessions for one year) individual therapy for culturally diverse students at UIC with a caseload of 14 weekly clients. Cultural backgrounds of clients include racial/ethnic students, LGBTQ students, low-come students, international students, etc. Presenting issues include anxiety, depression, interpersonal difficulties, suicidal and self-harm behaviors, complex childhood trauma, sexual assault and harassment, experience of cultural marginalization and oppression, etc. ⬧ Conduct 3 Initial Consultation/Intake assessments weekly and present recommendations for treatment and disposition at the weekly clinical meeting. ⬧ Lead a weekly Women of Color interpersonal process group. ⬧ Provide weekly supervision for a third-year doctoral extern in Clinical Psychology, focusing on one long-term therapy case. ⬧ Provide couple’s therapy to at least 1 couple during the second half of the training year. ⬧ Design and conduct outreach interventions (e.g., engineering freshmen orientation on mental wellness, multicultural practice workshop for medical students). ⬧ Provide weekly individual therapy for political refugees served at Marjorie Kovler Center who experienced violence and torture. ⬧ Receive 4.5-hour weekly individual supervision (primary, secondary, group therapy, and rotation supervision), 2-hour weekly group supervision (for group therapy and provision of supervision), and 4-hour weekly seminars (psychiatry, professional issues, multicultural, couple’s therapy, outreach seminars), and 2-hour weekly meetings (clinical meeting, group therapy consultation).

SUPERVISED DOCTORAL-LEVEL PRACTICUM EXPERIENCES Doctoral-Level Practicum Counselor (08/2018 – 12/2018) OASIS Alcohol and Drug Support Center, Indiana University, Bloomington, IN Supervisors: Heather Barrett, MSW, LCSW, Lynn Gilman, Ph.D., HSPP ⬧ Provided motivational interviewing and solution-focused therapy to college students who are mandated to receive counseling due to alcohol and drug violations on campus. ⬧ Led monthly psychoeducation groups and provided harm reduction information and techniques (e.g., the expectancy effect of drinking, the signaling system of the blood-alcohol levels, social-norms intervention for alcohol and drug use).

⬧ Attended Alcohol, Marijuana, and Motivational Interviewing Training, Opiate Overdose Reversal and Naloxone Training, and Trauma Survivors and Substance Abuse Training. ⬧ Received 1-hour weekly individual supervision and 2-hour monthly group supervision.

Doctoral-Level Practicum Counselor (08/2017 – 05/2018) Counseling and Outreach Program, Ivy Tech Community College, Bloomington, IN Supervisor: Lynn Gilman, Ph.D., HSPP ⬧ Conducted intake assessments, walk-in/on-call services, and individual psychotherapy for community college students. Clients included both traditional and non-traditional college students who came from predominantly White, rural, and low SES communities. Presenting issues included transition to college, anxiety, depression, emotional regulation, substance abuse concerns, sexual harassment, childhood trauma, etc. ⬧ Conducted emergency walk-in services for students who needed imminent mental health care. ⬧ Oversaw administrative tasks and provided training to student front desk staff on the procedure of greeting clients and ensuring client’s confidentiality. ⬧ Received 1-hour weekly individual supervision and 1-hour monthly group supervision.

Doctoral-Level Practicum Counselor (08/2016 – 05/2017) Counseling and Psychology Services, Indiana University, Bloomington, IN Supervisors: Paul L. Toth, Ph.D., HSPP, Emily Wheeler, Ph.D., Amanda Snell, Psy.D. ⬧ Conducted intake assessments and short-term (5 -10 sessions) individual psychotherapy for college students from diverse backgrounds with regard to race, ethnicity, country of origin, gender identity, sexual orientation, etc. Presenting issues included: generalized anxiety, social anxiety, depression, moderate risk level suicidality, body image concerns, substance use concerns, adjustment issues, parental issues, etc. ⬧ Attended 1-hour weekly multidisciplinary staff meeting and consulted cases with psychiatrists, psychologists, master’s level counselors, and social workers on staff. ⬧ Received 1.5-hour weekly individual supervision with a doctoral intern supervisor and 1.5- hour weekly group supervision with a licensed psychologist.

Doctoral-Level Practicum Counselor (In English and Mandarin) (08/2015 – 05/2016) Center for Human Growth, Indiana University, Bloomington, IN Supervisor: Michael Tracy, Ph.D., HSPP ⬧ Conducted intake assessments, walk-in/on-call services, and individual psychotherapy for college students and community members who came from diverse backgrounds. Presenting issues included: anxiety, depression, childhood sexual abuse, borderline personality disorder, etc. ⬧ Attended weekly staff meeting to present and consult on intake cases. ⬧ Received 1-hour weekly individual supervision and 2.5-hour weekly group supervision.

SUPERVISED DOCTORAL-LEVEL OUTREACH EXPERIENCES Doctoral-Level Mental Health Consultant (01/2019 – 05/2019) I Can Persist STEM Initiative, Indiana University, Bloomington, IN Supervisors: Kerrie Wilkins-Yel, Ph.D., Lynn Gilman, Ph.D., HSPP ⬧ Provided mental health outreach presentations for ICP participants, who are women of color who are undergraduate and graduate students studying STEM subjects at IU. ⬧ Conducted 30-minute brief consultation, assessment, and intervention focusing on issues

related to academic stress, imposter syndrome, racial and gender discrimination, relational difficulties, career development, and identity struggles being first generation college and graduate students. ⬧ Facilitated ICP participants in connecting with longer term mental health services and social support systems. ⬧ Received 1-hour weekly individual supervision.

Community Conversation Group Facilitator (01/2018 – 05/2018) Department of Counseling and Education Psychology, Indiana University, Bloomington, IN Supervisors: Kerrie G. Wilkins-Yel, Ph.D., Lynn Gilman, Ph.D., HSPP ⬧ Community Conversation is a one-session, two-hour group experience that provides undergraduate students with a “brave space” where we discuss topics related to multicultural awareness and cultural identities, for example, privileged and underprivileged identities, the intersectionality of cultural identities, institutionalized racism, sexual assault and harassment, the #MeToo movement, and immigration policies. ⬧ Led groups with a co-facilitator and engaged students in building “Brave Space Expectations.” ⬧ Designed and facilitated the group experience to include experiential activities, videos, podcasts, comics, and multicultural quizzes. ⬧ Moderated the discussions using listening, questioning, facilitative, and reflective skills. ⬧ Encouraged critical thinking and civil disagreements by exploring each group member’s socialization experience related to the topic. ⬧ Received 1.5-hour weekly group supervision.

Doctoral-Level Practicum Counselor (08/2017 – 05/2018) Counseling and Outreach Program, Ivy Tech Community College, Bloomington, IN Supervisor: Lynn Gilman, Ph.D., HSPP ⬧ Developed and engaged in outreach initiatives such as mental health outreach presentation at the orientation for international students. ⬧ Provided campus-wide depression screening service once a semester. ⬧ Provided consultation services to staff and faculty regarding students’ mental health issues. ⬧ Received 1-hour weekly individual supervision and 1-hour monthly group supervision.

Coordinator of Mandarin Counseling and International Students Outreach Services Center for Human Growth, Indiana University, Bloomington, IN (08/2016 – 07/2019) Supervisor: Lynn Gilman, Ph.D., HSPP ⬧ Served as the primary administrative contact for the Mandarin counseling team and oversaw the Mandarin counseling email account, assignment of new intake clients, and the planning and recruitment of Mandarin-speaking support groups. ⬧ Provided preliminary consultation to doctoral and master’s level Mandarin counselors. ⬧ Created promotion materials for the Mandarin Services such as flyers, postcards, and newsletters. ⬧ Coordinated distribution efforts to reach various entities on campus, such as the Office of International Studies, Dean of Students Office, Gradate Mentoring Center, academic departments, on campus apartments, student organizations, local church, and coffee shops. ⬧ Conducted workshops and support groups for international students, for example, a support group for students impacted by the Travel Ban, workshops on resources in Bloomington, interpersonal communication skills, and cultural differences in dating. ⬧ Prepared an annual report to summarize the services provided by the Mandarin team. ⬧ Chaired and organized 1-hour monthly team meeting with the supervisor.

Diversity Outreach and Let’s Talk Consultant (08/2015 – 05/2016) Counseling and Psychological Services, Indiana University, Bloomington, IN Supervisor: Paul L. Toth, Ph.D., HSPP ⬧ Responded to incoming outreach requests and provided workshops on mental health awareness, cultural diversity, and sexual assault and harassment. Student organizations and populations included: FASE (first generation college students), Asian Culture Center, Pi Lambda Phi Fraternity (a business fraternity), Alpha Kappa Alpha Sorority (a Black sorority), and graduate students of color. ⬧ Created a new outreach relationship with Indiana University Chinese Students and Scholars Association and provided a workshop on career development and mental health awareness. ⬧ Received 1-hour weekly supervision.

Step Up! Facilitator (01/2016 – 05/2016) Culture of Care, Dean of Students Office, Indiana University, Bloomington, IN Supervisor: Leslie Fasone ⬧ Provided 1.5-hour bystander intervention presentations in undergraduate classrooms and Greek life organizations. Topics included: sexual assault, drug and alcohol abuse, hazing, discrimination, harassment, mental health, and stress management. ⬧ Attended 1.5-hour monthly facilitators meetings, a 5-hour bystander intervention training, a 3-hour sexual misconduct policy and prevention training, and a 1.5-hour alcohol and drug awareness training.

INVITED OUTREACH PRESENTATIONS 13) Li, Y. (2018, November). Workplace sexism – A social dominance approach. Guest speaker presentation at EDUC G-375 Multicultural Counseling Related Skills and Communication, Indiana University, Bloomington, IN. 12) Li, Y. (2018, January). Social Cognitive Career Theory. Guest speaker presentation at EDUC G- 552 Career Counseling – Theory and Practice, Indiana University, Bloomington, IN. 11) Li, Y. (2017, November). Workplace sexism – A social dominance approach. Guest speaker presentation at EDUC G-203 Communication for Youth Serving Professionals, Indiana University, Bloomington, IN. 10) Li, Y. (2016, August). Bring your culture to IU. First Year Experience – IU Beginnings Program. Workshop presented at Asian Culture Center, Indiana University, Bloomington, IN. 9) Li, Y. (2016, April). Be a Hoosier. Step Up! Bystander Intervention Program. Guest speaker presentation at EDUC G-206 Introduction to Counseling Psychology, Indiana University, Bloomington, IN. 8) Li, Y. & Cheng, J. (2016, March). Keep calm and be assertiveness. Workshop presented at Asian Culture Center, Indiana University, Bloomington, IN. 7) Li, Y. & Wilson-Fernandez, M. (2016, March). Be a Hoosier. Step Up! Bystander Intervention Program. Workshop presented student organizations, Stop the Kyriarchy and Feminist Student Association, Indiana University, Bloomington, IN. 6) Li, Y. & Chen, R. (2016, February). Interview and job searching skills as a Chinese international student. Workshop presented at Indiana University Chinese Students and Scholars Association, Indiana University, Bloomington, IN. 5) Cheng, J. & Li, Y. (2016, February). Shared differences and similarities: A roundtable with international and domestic students. Roundtable collaborated with McNutt Community Educator and the Asian Culture Center, Indiana University, Bloomington, IN. 4) David, J., Miller, K., Zounlome, N., Li, Y., Li, S., & Wang, S. Y. (2016, February). The Untold Truths in the Black Families: Family Strengthening Event. Workshop presented at Alpha Kappa Alpha

Sorority, Indiana University, Bloomington, IN. 3) Li, Y., Cheng, J., & Cui, C. (2015, November). Mental Health Stigma Presentation. Presentation at Pi Lambda Phi Fraternity, Indiana University, Bloomington, IN. 2) Li, Y. & Cheng, J. (2016, October & November). Mental health wellness. Presentations at Minority Graduate Students Mixer, Indiana University, Bloomington, IN. 1) Saahir, M., Easter-Rose, C., & Li, Y. (2015, September & October). Time and stress management & Family pressures and expectations. Presentations at Faculty and Staff for Student Excellence Advisory Board meetings, Indiana University, Bloomington, IN.

SUPERVISED DOCTORAL-LEVEL SUPERVISORY EXPERIENCE Doctoral-Level Practicum Supervisor (01/2017-12/2017) Department of Counseling and Educational Psychology, Indiana University, Bloomington, IN Supervisors: Susan Whiston, Ph.D., LMHC, Lynn Gilman, Ph.D., HSPP ⬧ Provided weekly supervision to 3 master’s-level counselors. Two of them were practicum school counselors in elementary and middle schools; one was a practicum career counselor at the Career Development Center at Indiana University Bloomington. ⬧ Reviewed video tapes of supervisees’ sessions and provided feedback on progress notes. ⬧ Engaged supervisees in setting goals, identifying supervisees’ strengths and areas for growth, roleplaying foundational counseling skills and techniques , advancing case conceptualization skills, honing multicultural awareness and competence, conducting suicide assessment, processing transference and counter transference, enhancing ethical decision making skills, and exploring professional identity. ⬧ Received 1.5-hour weekly group supervision of the supervisory experience.

ADDITIONAL SUPERVISED DOCTORAL-LEVEL GROUP THERAPY EXPERIENCES Gratitude Group Facilitator (In English and Mandarin) (01/2016 – 05/2017) Department of Counseling and Education Psychology, Indiana University, Bloomington, IN Supervisors: Joel Y. Wong, Ph.D., Lynn Gilman, Ph.D., HSPP ⬧ The Gratitude Group Program is a six-session psychoeducation and skill-building group program that uses positive psychology principles and helps group members cultivate skills with regard to micro gratitude, gratitude savoring, interpersonal gratitude, redemptive gratitude, and macro gratitude. ⬧ Led the Gratitude Group with a co-facilitator and built a non-stigmatizing group environment by using positive terms (e.g., “group members” instead of “clients”) and appropriate self- disclosure. ⬧ Facilitated group members to explore experience related to experiencing and expressing gratitude and discuss their weekly gratitude journal. ⬧ Discussed and implemented cultural adaptations of gratitude practices in Chinese culture with Mandarin-speaking group members. ⬧ Received 1.5-hour weekly group supervision.

SUPERVISED MASTER’S-LEVEL CLINICAL EXPERIENCE Mental Health Counselor Intern (01/2014 – 12/2014) Living Resources, Albany, NY Supervisors: Allison Fuller, MSW, LCSW, Alex L. Pieterse, Ph.D., Hung-Bin Sheu, Ph.D., Kristin L. McLaughlin, Ph.D. ⬧ Provided individual counseling to individuals with developmental and physical disabilities. Presenting issues included intellectual disability, traumatic brain injury, depression, autism

spectrum disorder, delusional disorder, borderline personality disorder, etc. ⬧ Co-facilitated psychoeducation groups on topics such as social and interpersonal skills for clients with autism spectrum disorder, DBT skills for women with borderline personality disorder, and anger management. ⬧ Attend 2-hour weekly staff training on various topics such as psychotropic medication, policies and resources for individuals with disability. ⬧ Received 1-hour weekly individual supervision on site, 3-hour weekly group supervision with a program faculty, and 1-hour weekly supplemental supervision with an advanced doctoral student supervisor.

PSYCHOLOGICAL ASSESSMENT EXPERIENCES Received training in administering, scoring, and interpreting the following instruments as part of a course, a research project, or clinical practices: ⬧ Woodcock Johnson-III (Cognitive) ⬧ Wechsler Adult Intelligence Scale-IV (WAIS-IV) ⬧ Wechsler Intelligence Scale for Children-IV (WISC-IV) ⬧ Rorschach ⬧ Millon Clinical Multiaxial Inventory-III (MCMI-III) ⬧ Minnesota Multiphasic Personality Inventory-2 (MMPI-2) ⬧ The Sixteen Personality Factor Questionnaire (16PF) ⬧ Outcome Questionnaire-45.2 and Therapeutic Alliance (OQ-45.2, OQ-45.2 TA) ⬧ Behavioral Health Measure-20 (BMH-20)

ORGNIZATIONAL CONSULTING EXPERIENCE Project Assistant to Patricia Arredondo, Ed.D. (05/2019 – 08/2019) Arredondo Advisory Group ⬧ Participated in meetings with a client, which is a non-profit organization that provides housing for low-income individuals, and assisted in drafting a proposal of interventions to address organizational challenges. Proposed interventions included: diagnostic research (e.g., focus groups, survey data), board development, leadership training, communication skills training, and diversity, equity, and inclusion (DEI) training. ⬧ Assisted in developing a keynote address at the 2019 STEM Women of Color Conclave on the topic of empowering STEM women of color’s perseverance. ⬧ Assisted in developing an invited address at Ohio University on the topic of recruitment and retainment of minority faculty and students, specifically on strengthening the pipeline from high school to college for African American male students.

LEADERSHIP AND COMMUNITY SERVICE EXPERIENCES Student Representative (01/2019 – 12/2019) Section V: Psychology of Asian Pacific American Women, Division 35 (Society for the Psychology of Women), American Psychological Association ⬧ Designed mentorship programming to recruit and connect mentors and mentees within the division. Overhauled the logistics of the programming at the2019 APA convention, including creating advertising materials (e.g., flyers, emails), creating swags, purchasing refreshments at business meetings, making restaurant reservations, creating the agenda of the mentoring event, hosting the event, and documenting the event (e.g., photography).

Volunteer (10/2018-04/2019) Middle Way House, Bloomington, IN ⬧ Attended 20 hours training on providing hotline, on-scene, and legal advocate services to individuals who experience domestic violence. ⬧ Provided hotline services to callers who experienced domestic violence and inquired about the services at the Middle Way House and other local resources.

Mentorship Chair (08/2017 – 07/2019) Student Committee, Division 45 (Society of the Psychological Study of Culture, Ethnicity, and Race), American Psychological Association ⬧ Initiated the Virtual Mentorship series, which connected renowned psychologists with underrepresented undergraduate and graduate students in psychology. ⬧ Facilitated mentorship sessions on topics such as: Navigating Diversity Issues, Time Management in Graduate School, Clinical-Community Psychology Pathways and Work/Life Balance. Please see full programming at: https://tinyurl.com/y9lpg7pk ⬧ Conducted program evaluation by collecting students’ and mentors’ quantitative and qualitative feedback on the series. ⬧ Received the 2018 American Psychological Association Graduate Students Outstanding Award as the best student committee among all divisions in APA.

Co-Director of Research and Inquiry (02/2018 – 04/2019) Caught and Clogged Project, Funded by Commission of Ethnic Minority Recruitment, Retention and Training & Division 35 (Society for the Psychology of Women), American Psychological Association ⬧ Caught and Clogged is initiated by Drs. Cashuna Huddleston and Wendi Williams and aims at cultivating the flow in the leadership and career pipelines for diverse women of color. ⬧ Facilitated the programming of workshops that centered on empowering women of color in professional psychology. ⬧ Oversaw the research studies on the experience of the workshop attendees, including designing the studies and collecting and analyzing the quantitative and qualitative data.

Presidential Task Force Member (03/2018 – 07/2019) Next Generation Presidential Task Force on Graduate Students and ECPs, Division 45 (Society of the Psychological Study of Culture, Ethnicity, and Race), American Psychological Association ⬧ The Task Force was assembled by Division 45 Present-Elect Dr. Alvin N. Alvarez to blueprint initiatives during his 2019-2020 presidential term. ⬧ Attended monthly task force meetings and brainstormed Division 45’s outreach strategies to better serve and engage with undergraduate students, graduate students, and early career professionals in psychology.

The International Task Force Member (02/2018) Counseling Psychology Doctoral Program, Indiana University Bloomington ⬧ Assisted the program’s efforts to add an emphasis on international issues and perspectives in the current doctoral program curriculum. ⬧ Searched for research articles that address counseling, psychology, and assessment issues in the international context and recommended the readings be added to eight doctoral-level courses.

The Qualifying Exam Revision Committee Member (01/2018) Counseling Psychology Doctoral Program, Indiana University Bloomington

⬧ Assisted the program’s efforts to revise the qualifying exam for doctoral candidacy, including drafting exam questions and instructions and recommending required readings for the questions.

Graduate Student Convention Assistant (08/2016 – 08/2017) Division 45 Society of the Psychological Study of Culture, Ethnicity, and Race, American Psychological Association ⬧ Attended the Elective Committee meetings and Student Committee meetings. ⬧ Recruited and coordinated reviewers to review submitted APA proposals. ⬧ Facilitated programming and exhibition of Division 45 at 2017 APA annual convention.

Chair of Diversity Committee (07/2016 – 05/2017) Counseling Psychology Student Organization, Indiana University Bloomington ⬧ Initiated the “Peer-versity --- Messages on Multiculturalism” series, which was a peer-led multicultural panel discussion series that aimed at deepening multicultural awareness among graduate students in counseling and education. Panel discussion topics included multiracial individuals and gender non-conforming individuals. ⬧ Chaired monthly meetings with 3 other fellow graduate students and coordinated on efforts to consult faculty mentors on the events, invite graduate student panelists, advertise the events, moderate the discussions, and collect feedback from the audience. ⬧ Received the Innovative Multicultural Programming Award by the Commission on Multicultural Understanding at Indiana University Bloomington.

Continuing Education Committee Co-chair (09/2015 – 04/2016) Counseling Psychology Doctoral Program, Great Lakes 2015 Regional Counseling Psychology Conference ⬧ Assisted a faculty co-chair and evaluated the Continuing Education (CE) session proposals. ⬧ Provided feedback on the CE proposals and communicated with the authors to revise the proposals in compliance with Division 17’s CE guidelines.

APA Student Volunteer (08/2018, 2017, 2014) Division 17 (Society of Counseling Psychology) Hospitality Space, APA Annual Convention ⬧ Greeted and provided assistance to professionals who attended social events hosted by the Hospitality Space of Division 17.

TEACHING EXPERIENCES Associate Instructor (08/2015 – 07/2019) School of Education, Indiana University Bloomington, IN ⬧ Instructed undergraduate-level counseling minor courses for 4 academic years, included a total of 8 sections of EDUC G-206 Introduction to Counseling Psychology, 3 sections of EDUC G-203 Counseling for Career Issues, and 1 section of EDUC G-203 Communication Skills for Youth Serving Professionals. ⬧ Course components included: theories of psychotherapy and career development, foundational counseling skills, communication skills, multicultural counseling, and case conceptualization. ⬧ Evaluated students' in class performance, writing assignments, counseling role-plays, and group and individual presentations. ⬧ Wrote recommendation letters in assisting students’ graduate school application. ⬧ Received training on pedagogy through a yearlong weekly course, EDUC P-650 College

Teaching and Instruction, including topics such as learning theories, multicultural classroom, assessment on students’ learning, and providing students with feedback. ⬧ Received additional training through the Center for Innovative Teaching and Learning.

ESL Teacher for TOEFL iBT and IELTS (04/2012 -05/ 2013) Shanghai International Studies University, Shanghai, China Longre Shanghai Training Centre, Shanghai, China ⬧ Provided training on standardized language ability tests, TOEFL iBT and IELTS, for Chinese students who prepared to study abroad. The curriculum included: English grammar, listening and reading skills in academic settings, argumentative writing skills, and oral English skills. ⬧ Provided mentorship to students by hosting study abroad workshops, sharing information and experience about studying abroad in the U.S., and providing career guidance with respect to studying abroad.

EDITORIAL EXPERIENCES Book Proposal Reviewer (10/2018) Cognella, Inc. ⬧ Reviewed the book proposal of Career Counseling: Theory, Practice and Application by Janet Hicks and Mary Mayorga and provided comments and feedback about its application as a textbook for career counseling related courses in college.

Convention Proposal Reviewer (01/2018) Division 35 Society for the Psychology of Women, American Psychological Association ⬧ Provided comments and evaluation on submitted convention proposals.

Conference Proposal Reviewer (03/2016) Continuing Education Committee, Great Lakes 2015 Regional Counseling Psychology Conference ⬧ Provided comments and evaluation on submitted conference proposals.