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 ii Copyright © 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. iv 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. v 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 vi 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 ix Chapter I Introduction The importance of understanding racial/ethnic