Addressing Racial and Ethnic Microaggressions in Therapy -

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Professional Psychology: Research and Practice © 2014 American Psychological Association 2014, Vol. 45, No. 4, 283–290 0735-7028/14/$12.00 http://dx.doi.org/10.1037/a0037420 Addressing Racial and Ethnic Microaggressions in Therapy Jesse Owen Karen W. Tao and Zac E. Imel University of Louisville University of Utah Bruce E. Wampold Emil Rodolfa University of Wisconsin, Madison and Research Institute, Alliant International University Modum Bad Psychiatric Center, Vikersund, Norway This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Racial and ethnic microaggressions in everyday life can negatively impact the well-being of racial This document is copyrighted by the American Psychological Association or one of its allied publishers. and ethnic minorities (REM). When microaggressions are perceived in therapy they can interfere with therapeutic progress. However, little is known about whether microaggressions are addressed in therapy and if so, does addressing them impact the therapeutic relationship. REM clients from a university counseling center (n ⫽ 120) reported on their therapy experience. Approximately 53% of clients reported experiencing a microaggression from their therapist. Clients’ perceptions of micro- aggressions were negatively related to the working alliance, even after controlling for their current psychological well-being, number of sessions, and therapist racial and ethnic status. Of those clients who reported a microaggression, nearly 76% reported that the microaggression was not discussed. For those clients who experienced a microaggression and did not discuss it, alliance ratings were lower as compared with clients who did not experience a microaggression or who experienced a microaggression but discussed it. Keywords: alliance, cultural competence, microaggression, psychotherapy, rupture Overt forms of racism and prejudice have a long history in unconscious) insults, slights, and discriminatory messages. Sue the United States and they still occur today. However, less overt et al. (2007) explicated three specific types of microaggres- forms of racism and prejudice are more ubiquitous (Sue et al., sions: microinvalidations (e.g., denying that racism exists), 2007). Pierce et al. (1978) identified an insidious form of microassualts (e.g., more direct racism, but conducted in private cultural bias—racial microaggressions, which include the ex- or safe environments), and microinsults (e.g., believing the perience of a variety of direct and indirect (conscious and cultural norms of a group are pathological). A core character- istic of a microaggression is that it is ambiguous or subtle in nature, which is in contrast to an overt racial slur Microaggres- sions can target individuals’ cultural identities (e.g., gender, JESSE OWEN received his PhD in counseling psychology from the Uni- sexual orientation; Owen, Tao, & Rodolfa, 2010; Shelton & versity of Denver. He is currently an associate professor and training Delgado-Romero, 2011) and generally when they target indi- director at the University of Denver. His research interest includes multi- viduals’ race and ethnicity (e.g., subtle discriminatory mes- cultural processes in psychotherapy and psychotherapy outcomes and sages), as they are biased comments referring to nationality, processes. values, cultural customs, and language and can also be based on KAREN W. TAO received her PhD in counseling psychology from Uni- physical appearance (Pollard & O’Hare, 1999). Ethnicity typi- versity of Wisconsin, Madison in Counseling Psychology. She is currently cally refers to group membership related to a common cultural an assistant professor at the University of Utah. Her research interest includes cultural processes, psychotherapy outcomes, and processes. heritage, values, attitudes, and behaviors; whereas race is typ- ZAC E. IMEL received his PhD in counseling psychology from University ically defined by physical attributes (e.g., skin color) that is of Wisconsin, Madison. He is an assistant professor at the University of shared by a group of people (Cokley, 2007; Quintana, 2007). A Utah. His research interest includes psychotherapy outcome and processes. hybrid definition that integrates both race and ethnicity can be BRUCE E. WAMPOLD received his PhD in counseling psychology from useful in some cases (Cokley, 2007) and in particular for University of California, Santa Barbara. He is currently a professor at the therapy studies as therapists are reacting to both the clients’ University of Wisconsin, Madison and Modum Bad Psychiatric Center. His race and ethnicity during therapy. research interest includes psychotherapy outcomes and processes. Racial and ethnic microaggressions have been associated with EMIL RODOLFA received his PhD in counseling psychology from Texas psychological distress, such as anger, anxiety, confusion, and A&M University. He is currently a professor at the Alliant International University. His research interests include supervision, training, ethics, and contempt (e.g., Blume, Lovato, Thyken, & Denny, 2012; Mercer, boundaries. Zeigler-Hill, Hayes, & Wallace, 2011; Schoulte, Schultz, & Alt- CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Jesse maier, 2011; Wang, Leu, & Shoda, 2011). Many racial and ethnic Owen, Psychology Department, College of Education, University of Lou- minority (REM) individuals experience microaggressions in ev- isville, Louisville, KY 40292. E-mail: [email protected] eryday life, and unfortunately they also can be experienced during 283 284 OWEN, TAO, IMEL, WAMPOLD, AND RODOLFA therapy. For instance, clients are likely to perceive microinvalida- does not impede clients’ clinical goals (Constantine, 2007; Owen tions and microinsults1 from their therapists in the form of dismis- et al., 2011; Owen & Imel, 2010). sive or negating messages about their cultural heritage or culturally Given the deleterious effects of clients’ perceptions of micro- inappropriate interventions (Burkard & Knox, 2004; Neville, Lilly, aggressions on therapy processes, it is important to ascertain Duran, Lee & Browne, 2000; Salvatore & Shelton, 2007; Solór- whether therapists and clients are discussing these potentially zano, Ceja, & Yosso, 2000; Thompson & Jenal, 1994). Concep- negative experiences. Therapists may not be fully aware of the tually, microaggressions could be experienced by REM clients specific statement or action that the client perceived as a micro- (either tacitly or explicitly) as a recapitulation of previous cultural aggression, because microaggressions can be indirect, uncon- injustices, which when not properly handled could impede the scious, and unintentional. Generally, therapists are not good pre- therapy process. For example, a microinsult to an Asian American dictors of treatment process and outcome. For example, therapists client (e.g., “I don’t know why you just don’t speak up for yourself tend to underestimate the number of clients who deteriorate during and tell your parents how you feel”) potentially pathologizes the therapy (Chapman et al., 2012; Hannan et al., 2005). Moreover, client’s cultural ways of relating to elders. In doing so, the thera- therapists have been shown to be reluctant and uncomfortable This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. pist possibly jeopardizes the working alliance, as the client and when addressing issues of race and ethnicity (Knox, Burkard, This document is copyrighted by the American Psychological Association or one of its allied publishers. therapist will likely disagree on standing up to the client’s parents Johnson, Suzuki, & Ponterotto, 2003). Nonetheless, therapists as an appropriate method to alleviate the client’s distress with his should strive to be aware of how the client reacts to what they say family. Thus, therapists may need to be aware of the cultural and any potential changes in the therapeutic relationship (Safran & dynamics in the therapy process and be able to successfully nav- Murran, 2000). Ideally, therapists who are aware of potential igate these conversations (Cardemil & Battle, 2003; Maxie, Ar- problems can directly process the specific microaggression, seek to nold, & Stephenson, 2006). understand why it occurred, clarify misunderstandings, and work To date, there are only three known studies that have examined to realign with the client (Nadal, 2009; Safran & Murran, 2000). In racial and ethnic microaggressions in therapy with two samples of doing so, therapists should be able to repair the therapeutic rela- African American clients (n ⫽ 40, Constantine, 2007; n ⫽ 19, tionship. Currently, we are not aware of any data establishing Morton, 2011) and one sample was more diverse including ap- whether therapists attempt to mend the therapeutic relationship with clients after the presence of microaggressions. proximately 20% Asian American clients, 16% multiracial/ethnic We predicted that REM clients’ perceptions of microaggres- clients, 9% Hispanic clients, 1% African American, and 50% Euro sions would be negatively associated with their ratings of the American clients (n ⫽ 232, Owen et al., 2011). Moreover, there alliance (Hypothesis 1), after controlling for current psychological are only two other known studies examining microaggressions well-being, number of sessions, and therapist race and ethnic against women and LGBQ clients in therapy (Owen et al., 2010; status. The use of current psychological well-being as a control Shelton & Delgado-Romero, 2011). Despite the paucity of therapy variable should help reduce the likelihood that some of the vari- studies, one emerging trend is becoming clear: the experience of ance in the alliance are due to positive mental health or gains in microaggressions can lead to feelings of invalidation and/or dis- therapy (cf. Barber, 2009). Additionally, we predicted that client– respect, thus resulting in a rupture wherein the emotional bond therapist dyads that addressed the microaggression (and were able with a therapist is disrupted. For instance, in several analogue to come to resolution) would (a) demonstrate similar levels of studies, therapists’ endorsement of a specific type of microaggres- working alliance to clients who never perceived a microaggression sion— colorblind attitudes (Neville et al., 2000)— has been shown (Hypothesis 2) and (b) have higher levels of alliance than clients to impact aspects of the working alliance, such as their empathy whose therapist never discussed the microaggression or were un- toward an African American client (Burkard & Knox, 2004; also able to resolve the issue (Hypothesis 3). see Gushue, 2004; Neville et al., 2006). In actual therapy sessions, clients’ perceptions of racial and ethnic microaggressions were negatively associated with the quality of the working alliance Method (Constantine, 2007; Morton, 2011; Owen et al., 2011) as well as satisfaction with services and therapy outcomes (Constantine, Participants 2007; Owen et al., 2011). The negative association between microaggressions and the Clients included 88 females and 32 males with a median age of working alliance is of particular importance. First, the alliance— or 22 years old (range ⫽ 18 to 51). Thirty-one percent (24.2%) of the the agreement between the client and therapist on the goals for clients were graduate students, 28.3% were seniors, 20.8% were therapy and the methods to reach those goals as well as the juniors, 11.7% were sophomores, 13.3% were freshman, and 1.7% relational bond between the client and therapist (Bordin, 1979)—is were nonstudents. Clients were asked to self-identify their race/ one of the most robust predictors of therapy outcomes, accounting ethnicity; 1.7% of clients identified as African American, 42.5% for approximately 7% to 14% of the variance (Crits-Christoph et identified as Asian American, 24.2% identified as Hispanic, 30.8% al., 2011; Horvath et al., 2011). Accordingly, it is of utmost identified as multiethnic, and less than 1% did not identify their importance for therapists to attend to microaggressions that impact race or ethnicity. The small number of clients did not allow us to the ability to form or maintain a therapeutic working alliance. test for differences between racial and ethnic demographic groups. Second, the alliance has been shown to be a mediator for the association between microaggression and therapy outcomes, sug- 1 Therapists are less likely to use microassualts in session with clients gesting those client–therapist dyads who are able to maintain high because this subtype of microaggression is more conscious and resembles quality alliances are able to work through the rupture in a way that overt racism. RACIAL AND ETHNIC MICROAGGRESSIONS IN THERAPY 285 These figures are consistent with the overall university’s race and 0.48). As such, we created two scores for the RMCS: (a) ethnic composition, wherein Asian Americans represent 41% of whether microaggression occurred at all (Yes ⫽ 64 [53.3%]; the student body, Hispanic/Latino(a) students represent 16%, and No ⫽ 56 [46.7%]), and (b) a total microaggression score. For African American students represent 3% (note the university does the latter score, we included all clients including those who did not include multiethnic/racial as a category). not report any microaggressions. To do so, we treated ‘no Thirty-three therapists treated the 120 clients. The average num- reported microaggressions’ responses as the anchor point on the ber of clients reporting for each therapist was 3.64 (range ⫽ 1 to scale (i.e., 1) and then continued with the other rating points on 9). Ten of the therapists self-identified as REM and 23 self- the impact scale. For example, a client who experienced a identified as White. Therapists were not directly assessed in this microaggression but reported that it did not bother then at all study and subsequently further demographic or other therapeutic would have a score of 2 on the impact of microaggression score. information was not gathered. In general, the therapists were This scaling was done to include all clients. The total micro- predoctoral interns, postdoctoral fellows, staff psychologists, and aggression scale was consistent to creating a composite score by staff therapists. There is no prescribed therapeutic approach for summing the frequency and impact subscales. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. therapists. In prior assessments at this counseling center, where The reliability and validity of RMCS has been tested in three This document is copyrighted by the American Psychological Association or one of its allied publishers. therapists were asked to indicate their theoretical orientation in an separate samples (Constantine, 2007; Morton, 2011; Owen et open-ended format, all therapists indicated that they practiced al., 2011). To establish concurrent validity, Constantine (2007) some form of integrative therapy (e.g., psychodynamic/cognitive– found the clients’ scores on the RMCS were negatively corre- behavioral, relational/systems/cultural; see Owen et al., 2011). lated with their ratings of cross-cultural competency of White This counseling center generally provides brief therapy (6 – 10 therapists. Furthermore, the RMCS was negatively related to sessions; the median number of sessions for this sample was four). client rated working alliance and satisfaction with therapy, It is common practice at this counseling center for the therapist suggesting that the measure captures meaningful aspects of the who conducts the intake to continue to see the client for therapy. psychotherapy process (Constantine, 2007; Morton, 2011; Owen et al., 2011). Previous reliability estimates have ranged from .66 to .79 for REM clients. In the current study, the Measures Cronbach’s alpha was .88. Racial Microaggressions in Counseling Scale (RMCS; Con- Discussion of microaggressions. For clients who reported stantine, 2007). The RMCS was used to assess clients’ per- that they experienced a microaggression, they were asked if the ceptions of racial microaggressions during the course of ther- microaggression(s) was discussed in therapy. Specifically, they apy. It is a 10-item scale with items that assesses a client’s were asked the following: If any of the above occurred [microag- perception of counseling situations related to race or ethnicity. gressions from the RMCS], did you and your counselor discuss the Example items include the following: My counselor minimized issue(s)? and the response categories were Yes, and we were able the importance of cultural issues in our session(s), and My to work it out; Yes, and we were unable to work it out; and No, we counselor sometimes was insensitive about my cultural group did not discuss the issue. when trying to understand or treat my concerns or issues. We Working Alliance Inventory-Short Form (WAI-S, Tracey & retained the wording for the items; however we altered the Kokotovic, 1989). The WAI-S is a client rated measure of instructions and the rating scales. The original rating scale was working alliance that consists of 12 items that assess goals and a 0 (this never happened to me), 1 (this happened, but it did not tasks for therapy as well as the relational bond between the bother me), and 2 (this happened and I was bothered by it). The client-therapist. These items were rated on a seven-point scale existing rating scale can be characterized as a categorical rating ranging from 1 (Strongly disagree) to 7 (Strongly agree) with system, reflecting two dimensions: (a) if the microaggression higher scores indicating a better working alliance. The WAI-S happened or not, and (b) if the microaggression bothered the is a commonly used measure of working alliance and the client or not. Moreover, there might be reactions that could be reliability and validity has been demonstrated in numerous delineated between the ratings of it did not bother me and I was studies comparing the WAI-S to other working alliance scales bothered by it, (e.g., I was slightly bothered by it) that are and therapy outcome (see Horvath et al., 2011). For the current conceptually meaningful. Statistically, rating scales with few study, the total scale score was used and the Cronbach’s alpha response options can also impact the reliability of the measure, was .95. with rating scales that have 5 to 7 response options generally Schwartz Outcome Scale-10 (SOS-10; Blais et al., 1999). demonstrating better reliability estimates (Nunnally, 1978). As The SOS-10 is a 10-item scale designed to assess current psycho- such, to assess frequency and impact of microaggressions, logical well-being over the past week, which is rated on a seven- clients were instructed to First rate how often each situation point scale ranging from 1 (Never) to 7 (All the time or nearly all occurred, then rate how the situation affected you. The rating the time). The reference samples (n ⬎ 10,000) for the SOS-10 scale to assess frequency ranged from 1 (Never) to 5 (Always). were drawn from various clinical populations (e.g., inpatient, Next, clients were asked, in a separate question for each item, outpatient, college counseling centers) and nonclinical populations If this occurred, how much did it bother you? to assess the (e.g., adults from the community, college students; Owen & Imel, impact of microaggression, which was rated on a 5-point scale 2010). Across studies, the SOS-10’s reliability was: test/retest, r ⫽ ranging from 1 (Not at all) to 5 (Very much). .88 and Cronbach’s alpha (␣) ⫽ .91. Furthermore, the SOS-10 has The distribution of the scores was restricted for both sub- strong convergent and divergent validity as it correlates in the scales. The mean for the frequency ratings were M ⫽ 1.22 predicted direction with a variety of clinical and psychological (SD ⫽ 0.35) and for the impact ratings were M ⫽ 1.20 (SD ⫽ well-being scales and reliably discriminates between clinical and 286 OWEN, TAO, IMEL, WAMPOLD, AND RODOLFA nonclinical samples (see Owen & Imel, 2010 for review). The level variance ⫽ 0.15, p ⬍ .001, 95% CI ⫽ 0.12, 0.20; therapist Cronbach’s alpha coefficient for this study was .94. level variance ⫽ 0.01, p ⬍ .001, 95% CI ⫽ 0.001, 0.03). These results suggest that therapists vary in their clients’ average ratings Procedure of the alliance and microaggressions. However, some caution should be taken with these results as the ratio of clients per During intake at a large West Coast university counseling center therapist was small. clients were asked, on their intake card, if they would be willing to Next, we screened for differences in clients’ ratings of mi- receive a survey about their therapy experience. Clients who croaggressions based on therapists’ racial/ethnic status. The agreed were sent an email at the end of the academic quarter results were not statistically significant, b2 ⫽ ⫺0.04, SD ⫽ .08, directing them to an anonymous online survey. Three-hundred p ⫽ .64, 95% CI ⫽ ⫺0.18, 0.12, suggesting that REM clients fifty-seven individuals responded to the electronic survey (29% did not significantly differ in their report of microaggressions response rate); however, we only included clients who identified as when their therapist was White or REM. Similarly, when we an REM, participated in individual therapy, and identified their tested whether therapists’ racial/ethnic status would be associ- This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. therapist. For purposes of the research, participants initially com- ated with clients’ perception of microaggressions occurring at This document is copyrighted by the American Psychological Association or one of its allied publishers. pleted an informed consent form and then were then asked to all (yes/no), the results were not statistically significant, b ⫽ identify their therapist. Next, clients completed a series of instru- 0.57, SD ⫽ .30, p ⫽ .086, 95% CI ⫽ ⫺0.11, 1.12. In total, ment and other questions related to the functioning of the coun- 53.3% (n ⫽ 64) of REM clients reported experiencing a micro- seling center (not analyzed here). Clients were directed to identify aggression (68.4% of REM clients who were treated by REM and report on a specific therapist for the alliance and microaggres- therapists and 46.3% of REM clients who were treated by White sion measures. If clients identified multiple individual therapists therapists)3. The descriptive statistics and bivariate correlations they were excluded from the analyses. Furthermore, clients who for the variables in the study are presented in Table 1 and did not identify any therapist were also excluded from the analy- Table 2. ses. After completion of the study, clients were able to enter a raffle for $100.00 dollars. All procedures were approved by the Primary Analyses university IRB. We tested whether clients’ perceptions of microaggressions would be negatively associated with their ratings of the working Data Analysis Considerations alliance (Hypothesis 1). To do so, we predicted alliance scores by Psychotherapy data frequently violate a basic assumption of clients’ perceptions of microaggressions (total score), and we statistical testing—independence of observations—as multiple cli- controlled for number of sessions (level 1-grand mean centered), ents are treated by the same therapist. Multilevel models can current well-being (level 1-grand mean centered), and therapists’ correct for the biases that occur when this assumption is violated. race and ethnicity (level 2-REM ⫽ 1, White ⫽ 0). The results We conducted multilevel models with Bayesian estimation utiliz- supported our hypothesis, insofar as clients who reported stronger ing the statistical package Mplus 7.0 (Muthén, & Muthén, 1998 – alliances reported fewer microaggressions, after controlling for the 2012). Bayesian models are not based on normality assumptions or variability among therapists and the variance in the other control asymptotic results and provide better estimations for unbalanced variables (see Table 3). Of the control variables, only clients’ and small sample sizes (Hamaker & Klugkist, 2011), which is well current psychological well-being (SOS-10) was positively associ- suited for our study given that we had a moderately small number ated with alliance scores. of therapists and an unbalanced number of clients treated by each Of the 64 clients who reported experiencing a microaggression, therapist. In Bayesian models the results describe posterior distri- 76% (n ⫽ 42) reported that the microaggression experience was bution, which is the range of uncertainty left in the model after not discussed, 24% (n ⫽ 13) reported the microaggression was accounting data included in the model (Hamaker & Klugkist, discussed. Of these 13 clients, only one client reported that the 2011). Thus, larger posterior distributions mean that there is more discussion was not successful. REM therapists were less likely to uncertainty in the results. Credible intervals (CI), similar to con- discuss the microaggression experience as compared with White fidence intervals, are utilized in Bayesian models to help describe therapists (90.5% vs. 67.6%); however, after controlling for ther- the range of the posterior distribution. For more detailed overview apist effects, these differences were not statistically significant of Bayesian analysis see Hamaker and Klugkist (2011). (b ⫽ 0.78, SD ⫽ 0.37, p ⫽ .06, 95% CI ⫺0.04, 1.54). The lack of statistical significance is likely a result of the small sample size as Results there were only 10 REM therapists and 23 White therapists cou- pled with the fact that discussion of the microaggression experi- ence was a low base rate event. Preliminary Analyses Initially, we examined the degree to which therapists varied in 2 For simplicity we will just report the b value here, but it reflects the their clients’ ratings of alliance and microaggressions. Therapists median of the posterior distribution. 3 accounted for approximately 9.8% of the variance in their clients’ We also tested whether client reports of microaggressions differed ratings of alliance (client level variance ⫽ 1.19, p ⬍ .001, 95% among client racial/ethnic groups (e.g., African American, Asian Ameri- can, Hispanic, Multi-Racial/Ethnic). The results were not statistically sig- CI ⫽ 0.94, 1.61; therapist level variance ⫽ 0.13, p ⬍ .001, 95% nificant (p ⬎ .05). However, our sample size per group was relatively CI ⫽ 0.004, 0.61) and they accounted for approximately 6% of the small. Further, information about these differences can be requested from variance in their clients’ perceptions of microaggressions (client the first author. RACIAL AND ETHNIC MICROAGGRESSIONS IN THERAPY 287 Table 1 Table 3 Means and Standard Deviations for the Alliance, SOS-10, Summary of Multilevel Model Predicting Alliance by Clients’ and Microaggressions Perceptions of Microaggressions REM clients REM clients Effect b (SD) p value 95% CI with REM with White Scale therapists therapists information Fixed effects Intercept-alliance 4.88 (0.36) ⬍.001 4.29, 5.69 M (SD) M (SD) Range Total microaggression ⫺0.82 (0.21) ⬍.001 ⫺1.20, ⫺0.38 Number of sessions 0.04 (0.03) .11 ⫺0.01, 0.10 Alliance (WAI-S) 5.60 (1.17) 5.51 (1.09) 1–7 SOS-10 0.24 (0.06) ⬍.001 0.12, 0.37 Psych well-being (SOS-10) 4.98 (1.25) 5.16 (1.09) 1–7 Therapist ethnicity 0.16 (0.30) .68 ⫺0.41, 0.70 Microaggression (RMCS) 1.11 (0.25) 1.14 (0.43) 1–6 Random effects Therapist variance 0.26 (0.19) ⬍.001 0.06, 0.75 n (%) n (%) Total N Client variance 0.89 (0.13) ⬍.001 0.65, 1.15 This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Any Micro 26 (68.4%) 38 (46.3%) 38/82 Note. Ethnicity was coded 1 for REM and 0 for White. Coefficients are This document is copyrighted by the American Psychological Association or one of its allied publishers. No discuss micro 19 (90.5%) 23 (67.6%) 21/34a unstandardized effects. CI ⫽ credible intervals. Note. REM clients treated by REM therapists, n ⫽ 38; REM clients treated by White therapists, n ⫽ 82. WAI-S ⫽ Working alliance Inventory- Short Form; SOS-10 ⫽ Schwartz Outcome Scale-10; RMCS ⫽ Racial client and therapist dyads where there were no reported microag- Microaggression in Counseling Scale. gressions (p ⬍ .05, d ⫽ ⫺0.56, 95% CI ⫺0.79, ⫺0.34). a There were nine missing cases for the discussion of microaggression item, thus the number of clients reporting a microaggression slightly exceeds the number of clients reporting on whether a discussion of the Discussion microaggression occurred. Many REM clients may have experienced microaggressions in daily life (e.g., Sue et al., 2007), and our results suggest that these societal experiences of discrimination do not stop at the therapy To address our second and third hypothesis, we examined three door. Indeed, 53% of REM clients in the current study reported groups: (a) client and therapist dyads who successfully discussed that a microaggression occurred in their therapy (any score on any the microaggression experience, (b) client and therapist dyads who item above the rating of Never). Moreover, clients’ perceptions of did not discuss the microaggression, and (c) client and therapist microaggressions were related to lower quality alliances with their dyads where there were no reported microaggressions. There was therapists. Consequently, our findings add to the other three stud- one client who discussed the microaggression experience but it ies that have demonstrated that clients’ perceptions of racial and was unresolved, thus this client was excluded from comparisons. ethnic microaggressions are negatively associated with the alli- Table 4 shows the means and standard deviations for the three ance—a central element in the therapeutic process and significant groups. The results demonstrated that alliance scores were signif- mediator between clients’ perceptions of microaggressions and icantly different among the three groups (b ⫽ ⫺0.27, SD ⫽ 0.08, therapy outcomes (Owen et al., 2010). p ⬍ .001, 95% CI ⫺0.44, ⫺0.12). As seen in the table, client and Conceptually, microaggressions can be thought of as a special therapist dyads who successfully discussed the microaggression case of ruptures in therapy, wherein experiences of discrimination experience had alliance scores comparable with clients who did and oppression from the larger society are recapitulated, which not perceive any microaggressions (p ⬎ .05, d ⫽ ⫺0.15, 95% places the therapeutic relationship under duress and strain. In the CI ⫺0.40, 0.10; supporting Hypothesis 2). Client and therapist current study, only 24% of client and therapist dyads discussed the dyads who successfully discussed the microaggression experience microaggression experience. Given that therapists are not gener- had higher alliance scores as compared with client and therapist ally proficient at identifying clients who are deteriorating in ther- dyads who did not discuss the microaggression experience (p ⬍ apy (Hannan et al., 2005), this finding might be a multicultural .05, d ⫽ 0.42, 95% CI 0.73, 0.12; supporting Hypothesis 3). Client variant of a similar phenomenon. Indeed, the very nature of mi- and therapist dyads that did not discuss the microaggression ex- croaggressions as subtle, unconscious, and indirect may prevent perience had significantly lower alliance scores as compared with well-meaning therapists from recognizing that their clients are experiencing such offenses. Moreover, therapists have been shown to be reluctant and uncomfortable when addressing issues of race Table 2 Bivariate Correlations Between Working Alliance, SOS-10, Table 4 and Microaggressions Means and Standard Deviations for Alliance by No Discussion Any micro Total micro Alliance SOS-10 of Microaggressions, Successful Discussion of Microaggressions, and No Microaggressions Any micro — Total micro .21ⴱ — No discussion Successful discussion No micro Alliance ⫺.21ⴱ ⫺.28ⴱⴱ — (n ⫽ 42) (n ⫽ 12) (n ⫽ 51) SOS-10 ⫺.17 ⫺.27ⴱⴱ .41ⴱⴱⴱ — Alliance 5.17 (1.21) 5.65 (0.91) 5.80 (1.06) Note. These correlations do not account for therapist effects. Any micro was coded 1 ⫽ Yes, 0 ⫽ No. Note. One client reported that the discussion of microaggression was not ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001. successfully resolved, but his/her/their scores are not reported here. 288 OWEN, TAO, IMEL, WAMPOLD, AND RODOLFA and ethnicity (Knox et al., 2003). Nonetheless, therapists are impacted by microaggressions based on the racial and ethnic responsible for the well-being of their clients. breakdown. We also acknowledge this decision to aggregate the Client and therapist dyads that were able to successfully sample preferences nomothetic (e.g., Students of Color) over id- discuss the microaggression experience had higher quality al- iosyncratic (e.g., Vietnamese American compared with Mexican liances as compared with client and therapist dyads where the American) information. Accordingly, our sample limited our abil- microaggression experience was not discussed. In fact, client ity to test potentially important distinctions within and between and therapist dyads who successfully discussed the microag- racial/ethnic groups as well as differences for particular cross- gression experience had similar alliances as those client and racial/ethnic therapist-client dyad pairings. Future research may therapist dyads where there was no perceived microaggression. want to examine whether and how microaggressions are experi- These results illuminate the power of addressing the missteps enced differentially among the various racial and ethnic groups. that can occur in therapy (see Safran & Murran, 2000). More- Third, this study caries the typical strengths and limitations of over, they are consistent with the positive effects of resolutions data sets obtained in naturalistic settings. As such, we sacrificed to ruptures in nonmicroaggression studies (e.g., Muran et al., more rigorous controls (e.g., prescreening, training therapists, This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 2009). At present and given the cross-sectional nature of our monitoring interventions) for a larger, more diverse sample, and This document is copyrighted by the American Psychological Association or one of its allied publishers. study, it is unclear whether the initial alliance was stronger for naturalistic treatments. Lastly, we adjusted rating scale for the client and therapist dyads who successfully addressed the mi- RMCS to provide separate ratings for frequency and impact of the croaggression as compared with the dyads who did not address microaggression. The distinction between frequency and impact the microaggression. may prove to be important in understanding how microaggressions can influence the process of therapy. For instance, why are some clients who perceive microaggressions not as impacted? Unfortu- Limitations and Future Directions nately, our research design does not allow us to fully test these The merits of our results should be interpreted within the scope hypotheses. Moreover, the scores on the RMCS were restricted, of the study’s methodological strengths and limitations. First, the suggesting that clients do not generally report that microaggres- retrospective nature of this study coupled with the electronic sions occur frequently throughout treatment and they do not report survey methodology raises several concerns: (a) inability to cap- that the microaggression experience bothered them a great ture session by session process of alliance and microaggressions, deal—at least based on scores on the ratings scale. These findings (b) our findings are correlational making the directionality of parallel the frequency and impact of microaggressions in previous microaggressions and alliance correlations potentially bidirec- psychotherapy studies (Constantine, 2007; Morton, 2011; Owen et tional, and (c) the response rate (29%) was relatively low. All al., 2011). The restricted range on the measures does not neces- known microaggression studies have utilized the same methodol- sarily minimize the importance of microaggressions; rather, it ogy (Constantine, 2007; Morton, 2011; Owen et al., 2011), and in appears that even modest ratings of microaggressions can have a our opinion the lack of research examining racial/ethnic microag- deleterious effect on the process and outcome of psychotherapy. gressions (only three studies) as well as therapists multicultural competencies in actual therapy settings is particularly hampering Implications for Training and Practice for the progress of our profession. There are many questions that can be untangled by assessing microaggressions in a prospective Given the complexity of microaggressions it is likely that all manner, including how the alliance changes after a microaggres- therapists will have clients who experience them. The overwhelm- sion and how client and therapists are able to address the experi- ing aspect of microaggressions for many clinicians and trainees is ence. Potentially, therapists’ ability to establish a sound relational that they are often unconscious and unintentional. What we have foundation early in therapy may enhance therapy process by pro- learned about the microaggression research, however, is that no viding a safe environment, which may lend itself to having dis- therapist is immune from unintentionally offending or invalidating cussions about microaggressions. There may be advantage to as- their clients. Therapists must realize that developing a strong sess microaggressions via therapist rating to gauge the degree of multicultural orientation requires a lifelong process of a willing- overlap in perceptions. ness to examine biases, attitudes, and beliefs— ultimately reflected Second, we only assessed microaggressions related to clients’ in a cultural humble stance with clients (Hook et al., 2013; Owen, racial and ethnic identity, whereas other types of cultural identities Tao, Leach, & Rodolfa, 2011; Owen, 2013). Accordingly, students (e.g., gender, sexual orientation) were not explored. Future studies in counseling programs must be introduced to the concept and should continue to examine the potential intersection of gender and impact of microaggressions early on in their training and beyond ethnicity, for example, in relation to the experience of microag- the multicultural counseling class. Core courses such as counseling gressions. Moreover, between racial/ethnic group comparisons on skills, ethics and professional issues, and practicum should also their perceptions of microaggressions was not statistically signif- incorporate activities and readings that allow students to explore, icant; however, we did not have sufficient sample size to fully test both didactically and experientially, the ways in which microag- these differences. Consistently, the limitations of restricting a gressions manifest (e.g., implicit or unconscious biases) as well as study to a single institution with disproportionality in racial and how they contrast to more explicit or overt forms of racism. ethnic demographics compelled us to combine racial and ethnic Moreover, the open endorsement of egalitarian or nonprejudiced minority clients into one group. We recognize this constrains views is not a reliable indicator of an individual’s awareness about interpretation regarding differences between how specific groups their biases or stereotypes. In fact, evidence suggests those who historically and currently experience racism or discrimination in consider themselves politically liberal are often at greatest risk of the United States or how specific groups on this campus may be maintaining implicit bias or rationalizing their beliefs through RACIAL AND ETHNIC MICROAGGRESSIONS IN THERAPY 289 nuanced ways (e.g., microaggressions). To address these issues, overall well-being (Constantine, 2007; Owen et al., 2011; Wang instructors and clinical supervisors are in a critical position to help et al., 2011). trainees process the phenomenon of microaggressions and other forms of contemporary prejudice (e.g., aversive and modern rac- ism) and recognize its cost to all (McConahay, 1986; Pearson, References Dovidio, & Gaertner, 2009; Sue, Lin, Torino, Capodilupo & Ri- Barber, J. P. (2009). Toward a working through of some core conflicts in vera, 2009). In turn, students will then be able to develop a psychotherapy research. Psychotherapy Research, 19, 1–12. doi: ‘language’ and ‘consciousness’ for talking about such interper- 10.1080/10503300802609680 sonal conflicts and engage in ‘difficult dialogues’ with their clients Blais, M. A., Lenderking, W. R., Baer, L., deLorell, A., Peets, K., Leahy, about their racial/ethnic identities (Sue et al., 2009). L., & Burns, C. (1999). 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