How Unaddressed Cultural Differences Affect the Therapeutic Relationship

Unacknowledged cultural differences lead to patient ambivalence and mistrust in the therapeutic relationship.


Health disparities stemming from structural racism have recently been exacerbated due to the COVID-19 pandemic. People from ethnic minority backgrounds typically experience a higher number of negative life events, life stressors such as debt, and more significant psychological distress.

Yet the mental health field has yet to fully appreciate the extent to which institutionalized clinical practice – not to mention institutionalized racism within the psy-disciplines – affects people of color seeking care. Indeed, most therapeutic interventions have been developed to address the issues and concerns of the educated middle class, which, in the US, is largely white. A new study on cultural differences and the clinical relationship aims to shed light on this fraught area of clinical practice.

There is evidence that strong therapeutic relationships could help to alleviate endemic, racialized health disparities. For example, a meta-analysis of 295 studies on the association between the therapeutic alliance and outcome in adult psychotherapies revealed that alliance was positively related to treatment outcome across all therapies, cultural contexts, and client characteristics. Yet the present study indicates that in the presence of racial and cultural differences between clients and mental health treatment providers, a strong alliance was not present in over half of the cases analyzed.

Woman Having Counselling SessionIn the study, Doctors Neil Aggarwal, Daniel Chen, and Roberto Lewis-Fernandez recruited 27 mental healthcare patients to complete a “cultural formulation interview” as part of their intake session to establish care with a provider. Two of the participants were white; fourteen identified as Latinx; eight as Black; and three as Asian.

The interview questions were designed to determine the participants’ level of trust or ambivalence towards their new providers. And in fact, more than half of the individuals surveyed indicated that they felt mistrust or ambivalence towards mental healthcare clinicians.

In an illustrative exchange with a 50-year-old white male social worker, for example, a 30-year old Black woman who participated in the study, when asked to evaluate her relationship with her treating psychiatrist, said:

“I really didn’t find it helpful … I don’t know. I don’t know. Probably she just – [it] was a misunderstanding. Probably she misunderstood me.”

As a 24-year-old Black Latina participant reported, regarding her white female social worker:

“I always had a wall up just speaking to somebody about my whole background. Even just having to think about my background or even, like, reliving that lifestyle just for a second, it hurts.”

Understandably, participants like these who perceived strong social, cultural, and racial differences from their treating providers expressed mistrust, ambivalence, and unsureness about their efficacy and about the therapeutic relationship itself, leading to disengagement from mental health services altogether.  As the authors of the study hypothesized, this “elevated disengagement from mental health treatment among Black, Indigenous, and people of color (BIPOC) patients may be due in part to their perceptions that providers misunderstand their experience because of differences in the cultural background that are not discussed in therapy.”

Exacerbating this disengagement is the strong evidence that psychotherapy is not ‘class neutral’ and that clients from working-class backgrounds might be systematically disadvantaged in psychotherapeutic contexts.

In analyzing these findings, the authors conclude:

“Delaying discussions of differences may reinforce patient mistrust by communicating that therapists do not care about patients’ experiences.” Yet it is unclear if mere discussion of difference goes far enough to rectify the ever-widening gap in experience of everyday material existence between social classes and racialized populations, on the one hand, and the professional class of mental health workers who are endowed with education – and often racial and class – privilege.“



Aggarwai, K.A., Chen, D., and Lewis-Fernandez, R. (2022) “If you don’t ask, they don’t tell: The cultural formation interview and patient perceptions of the clinical relationship. Am J Psychotherapy (advance online publication). (Link)


  1. Interesting that the article’s title refers to cultural differences but that the issue is then defined solely in terms of race as if race and culture are the same thing (i.e., everything else being equal, there cannot be any meaningful differences between a white American and a white French person, or an African-American and someone from Kenya?)

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  2. The irony of the culture vs race as noted by Truth793810 is that outside of USA: there is no difference between black and white Americans to the rest of the world.

    White Americans think they are so different from black Americans until they go abroad and people project the American culture that the whites think is black culture. It is often hilarious event to see if it was not also painfully so true.

    Culture in therapy is more about the mindset, the belief systems, the meaning of mental health itself, the meaning of healing, the meaning of trauma, and the nuance of power between people (authority or otherwise), and real definitions of body and mind etc.

    In therapy, I want to add, yes black and whites of America are different inside the country but often the main issue is blacks see themselves as whites see them versus who they are without the whites’ projections. Very different stance in the mindset.

    Deep stuff that is not often easy to see.

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    • I wouldn’t say there is no difference between (in general) between white and black Americans but they do have more in common than either of them tend to think.

      Also I would agree that African-Americans see themselves more through whites’ eyes than the latter realize, but it is not always the case.

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  3. I regard being a schizophrenian a cultural heritage if not a planetary star travelling one.

    Like gypsies, my grandfather was born from the loins of a gypsy woman, I think there has been an attempt to corral the psychic and mystical and poetic freedom inherent in my native schizophrenia.

    Schizophrenic people have been herded into asylums and this we must not forget. But how can we memorialise that dark chapter in schizophrenia culture’s history if we are no longer allowed to use that name? How can we celebrate our unique differences and our art and our regalia and lingo and our lore if we are deemed an embarrassment to antipsychiatry and an embarrassment to psychiatry? Like the gypsies in my grandfather’s time, schizophrenics are not welcome in most places.

    Someone spoke of how those in antipsychiatry should not forgive.

    We are crossing into hyper logical times where “right” or “wrong” is the only reaction you get a thousand times a day. Humans cannot thrive under the tyranny of such “judgement”. Harsh judgement is on one side. Forgiveness on the other.

    Forgiveness tends to be more emotion based than judgement, which from thinking that is linear and analytical.

    I do not believe abuse should be forgiven. I do not believe cruelty should be forgiven. I do not believe gross or vicious bullying should be forgiven. When I say bullying I mean that which puts bruises on a person.

    Aside from those mainstays, I personally like to forgive again and again and again.

    I feel forgiveness is a faster emotional route to inner freedom and wellbeing than simmering in resentment, bitter gall mostly fed by thinking over the past. But that is just me. It is only my free choice. I know that it is not for others.

    If I take those mainstays and set them aside I can mull over petty slights and disappointments and heartaches that occurred in my life that were NOT abuse meted out to me, nor cruelty, nor traumatic bullying.

    I think our civilzation is losing its proper grown up comprehension of what the tragedy of abuse actually is. The sexual rape or violation of children. Never forgive abuse.

    Slights and heartaches and disappointments are increasingly lumped with abuse as if, as a grown up, to be let down by someone is equivallent to the assault on an actual child.

    I see this as a sickness. Society’s emotionless, numb “love affair” with “rationalism” has permitted everyone a “rational” assertion to regard a missing Valentine card as the same catastrophe as a beaten up childhood.

    There is a link between “logic” then “right” and “wrong” then “judgement” then “entitlement”.

    The entitled used to be a rare phenomenon. Narcissistic persons perhaps. But since the explosion of awareness of narcissistic personality disorder, something everyone and everyone’s cat has, there has been a weird entitlement to point the accusatorial finger at other entitled individuals and call them entitled demanders who traumatize and who therefore need, by the laws of entitlement, to be sketchily judged, chastened or changed.

    It goes from a notion of an inadvertant or trivial “abuse” to “judgement” to “entitlement” to be made all better by getting the other to “change who they intrinsically are”, and if they do not “change” they get rejected.

    Forgiveness is the relinquishment of “entitlement”. Forgiveness becomes its own healing nourishment. But forgiveness takes a long time. Cannot be forced. That would be an incursion in itself.

    Puppets on strings grow by the hour and day. More and more people are being taught that acceptance is worthless UNLESS it is…

    “You have to accept me in THE SAME WAY that I accept me”.

    When you meet with that embodied uptight statement from someone it means that as a person you cannot just like someone the way you like to like them. You must get “lessons” in exactly which bits of them you “have to” adore. Which qualities they insist you enshrine. But these days that old type of vanity has been put out to pasture. A new vanity has it that you have to like their survivor feats, their appalling history overcome. But for that, it means you cannot have a worse history. A prettier history. A more long suffering culture. No, no, the person is to be the only one to have been abused and if you fail to affirm it to them then you are as unforgiveable as who ever did not send the valentine’s card.

    There has been a shift in society that has everyone being like joggled puppets on strings, shaking at whomever they deem too forgiving. This is linked to the mantra of…

    “To accept me you have to accept me as if you are another me and not as who you are, this means you must accept me scrupulously properly and only in using the correct language, not your gypsy language”.

    You may be devoted to the person. You may faint with joy when they call you. You may treasure all their idiosyncrasies. You may revel in their lovely unique differentness. But all of this means nothing if you do not love them in the correct way they tell you to.

    I sometimes see it as like when my Downs syndrome friend embraces everyone equally. She gives the love no one else does. She cannot do “correct”. When all the entitled “correctophiles” in the world leave you abandoned and cold she will welcome you unconditionally. She embodies nomadic tribal hospitality, that dying tradition, where the stranger is loved not because they are known but because they aren’t.

    How can you be “correctly accepting” someone you do not know?

    Or how can you ever be entitled enough to judge someone as not accepting you “properly” who does not know you?

    I will tell you how.

    Psychotherapy has been infiltrated by false leaders who preach that some people ShOuLd Know you. They should know you so psychologically intimately because psychology is the default factory setting of all unique individuals. Everyone should know what makes you cry. Everyone should know what makes you grin. Everyone should know what special food you eat, like you are a rare leopard in a conservation zoo. Everyone should know that you do not like your fork placed under the side of your plate. Everyone should know that you do not do handshakes. Everyone should know that you have no money, or too much money, or dribs and drabs of money. Everyone should know you like to sleep gradually and not in a sudden descent. Everyone should know your parents wrecked you. Everyone should know you are going through hell. Everyone should know what it took to get you here in one piece. Everyone should know you have had enough and cannot carry on looking after everyone anymore. Everyone should look appalled at themselves for not knowing all this enough, or deeply enough, or reciting it ten times a day, like a religious catechism or a sacrament. Everyone must be taught that you do not feel accepted until you are accepted in the above way. Accepted for being uniquely you.

    It is all coming from the way psychotherapy made a holy relic of the infant. And since we all as grown ups go around with an inner infant aspect, one we have lost touch with, our aim to get back to being connected to with our infantile feelings is marred by society’s emphasis on “logic” and “right” and “wrong”. No infant’s feelings are “right” or “wrong” or even fully known to the infant in any “logical” way. An infant at the breast does not order you to accept it “correctly” or it means you do not. To the infant, the infant is a complete mystery to itself, as are “you” as “other”. A mystery is accepted as something that is almost a living thing, ever evolving, that might make itself known or not. Much of human relationship is an energy flow between two people that is a complete mystery.

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    • Did I write that waffle?

      I see I must be clearer and say it like a five year old.

      1. A bully pesters people to love them in precise ways. Correct ways. Often impossible ways.

      2. When the people cannot love in the ideal way this then gives the bully the excuse to pummel the failures for being unloving.

      3. The bully may have only wanted to pummel all along, since pummelling with impunity feels lovely…as if being permitted to beat a school peer is that crying peer’s way of being loving….letting the bully get away with anything…even cruelty.

      4. To the bully their being allowed to be cruel seems like a loving tolerant response from the persecuted.

      5. The bully needs this manner of what they call love rather than the love that the other creates in their own heart and soul.

      6. The bully’s version of love is something the bully feels they are entitled to. The righteous entitlement matters to the bully since its not being properly served legitimates an explosive smash and grab at love, or a punitive shunning of the other as if they are lovelessly “evil” for not putting up with aggressive demands.

      7. Endemic in our times is the disregard of all other age groups but the metaphorical adolescent. The supreme symbol of assertion. There is a healthy and healing necessary aspect to the assertion to be loved in a specific way. But there is an unhealthy and confusing aspect to seeing such assertion of preferences as the only kind of love valid. A relationship is not all about every one of your millions of your own “free choices”, since you have made an intial choice to factor in the wellbeing of the intimate other. Therefore what the other deems as love is also valid. Nobody should be imposing their idea of love on anyone twenty four seven. Imposition and love are two words that do not make for good partners.

      7. What psychotherapy has inadvertantly done is push society toward the expectation of a welcome response to personal entitlement. This works great for clients who live under the shadow of “the entitled”. The actually domestically abusive. They need to fight fire with fire and so they learn in psychotherapy to pump up their own entitlement to have a quality of love that does not bruise them. The matching of like for like, entitlement for entitlement gives the illusion of a balanced form of love. But when prancing around with superior demands to be indulged upon night and day this tips over into flagrant bullying. The one on the receiving end is flustered by the idea the entitlement presented by the bully is asking for “love”. Psychotherapy has inadvertantly been describing the phenomenon of unloving cold parents as if they are assassins of the tender infant psyche.

      8. A person grows up and feels awful due to the usual tragedies that take place in the unfair world. The person’s inner infant feels broken by that year after year. The person reads a glossy article by psychotherapy that says all infants are entitled to be adored by their parents. The list of “proof of adoration” is no longer just the purchase of school shoes and jolly birthday gifts and a million pleasantries the likes of which a starving Ethiopian infant seldom sees, but the list must now include being hailed in the “right” way, spoken to with the “right” vocal inflections, understood in the “proper” way, and on and on and on and on and on and on.

      9. A billion parents now have grown offspring who never call them to see if they have fallen downstairs or need help getting food. The offspring have been encouraged by psychotherapy to lambast their parents and go no contact. But this entitled demanding for the sake of a idea of perfect love overspills into other kinds of important relationships. To the extent relatonships become violent and loveless. Each person is taught to pursue only perfect love. Nothing less than this servant master relationship will suffice. Until a billion people become utterly unliveable with and unloveable because of the escalation of their imperious bullying. A bully is deep down a tragic unwell person who ought to love themselves so much that they do not need anyone else to.

      10. In psychotherapy’s business model of pest control and going after problematic parents as if they are the convenient demons, pricked witches in our modern serving of the centuries long Inquisition, psychotherapy has failed to put the responsibility back on the individidual to love themselves, and futhermore love themselves imeasurably and FOR NO GOOD REASON. Psychotherapy has been complicit in schooling the masses to think love and reason must go together. There has to be “a logical reason” why the person loves themselves, they cannot just love themselves because they FEEL they are loveable to themselves. They have to be tutored by psychotherapy that the “reason” they do not is because of demon parents or trauma or abuse or neglect, and so it follows there must be a “reason” why they subsequently, after many sessions, have a eureka moment and do love themselves.

      11. But love is not a thing of “reason”.

      12. You cannot make a business out of something illogical and unreasonable and unfathomable and mysterious as “feelings” intrinsically are. Not unless you recognize that simple reality. Which psychotherapy used to do originally. It once was the troubador of the patently idiotic and “irrational” parts of human depths. Which is why in the nineteen sixties people started flocking to therapy like Hippies dropped out and flocked to Woodstock. But since then psychotherapy became more and more beholden to proving its legitimacy to the “logical” marketplace. It became itself uber “logical” and grew a multitude of pompous paradigms, each apt to tell people how to get “right” love, scientifically ratified love. It then had to rake up “wrong” love and demonise it. Conveniently this made populations anxious about whether they had ever had impressive “right” love. As if that “right” love could only ever be found brimming over in the milky eyes of the adoring. As if the best love could not be found by you yourself madly and passionately and for no good “reason”. No, according to psychotherapy magistrates the love has to now come from your partner twenty four seven, your mother twenty four seven, your father twenty four seven, your neighbour twenty four seven, a commenter on social media twenty four seven, your own kids twenty four seven. But all.l you find is that they love this about you but flatly do not love that about you. So it cannot be perfect “right” love. It must be assasination love, or murderous love, or cheating love, or lying to you love, or narcissistic love, or sinister manipulative love, or any other form of “wrong” and “illogical” and “unreasonable” love. Until love becomes synonomous with hatred and damage and danger.

      Then what?

      Then where are you going to go?

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  4. I add one major point.

    Children are not only entitled to a life free of sexual or any form of abuse. Children have a HUMAN RIGHT in the DECLARATION OF HUMAN RIGHTS NEVER TO BE ABUSED.

    We MUST do more to STOP the sexual abuse of children.

    Who are abusers. Sometimes bullies veer towards a “logical” way of perceiving life. They can do so as an escape from overwhelming “feelings”. A “logical” mindset sees things in terms of “right” or “wrong”. It is not that these are not essential in life but bullies take it to the extreme and they may keep their feelings under control by regarding emotion as “wrong”. They then may find it easy to tell others that their emotions are “wrong”. And they may also be unable to “feel” empathetic “feelings” towards the emotional as they do so. Bullies like the opposite of “feelings”. They like order and rational thinking and discipline and rules and this makes them enshrine decency. But it is an implaccable feelingless form of decency and they may have no quibble about enforcing such numb unempathetic decency on others. At some point living a feelingless life disintegrates and an explosive binge into depravity can occur. The bullies then try to tidy that up and blame the other for “leading them astray from the orderly life of decency”.

    In these ways too strict a life of emotional denial can lead to explosive loss of control.

    We live in an era where psychotherapy has let the cat out the bag in terms of fostering a belief that it is healthy to go around town with a sense of entitlement that needs cossetted and pandered to. Psychotherapy has produced “logical” reasons why people should pander to the entitled bullies in our midst. The overly decent. The “righteous”. The “rule pushing” imposers. By doing so psychotherapy has hushed up the voices of the abused who cry out against being met with entitled demanders. Confusingly those demanders may masquerade as victims who need perfect love. Which means people have to shut up and not get emotional while the bullies binge all over them in a “logically” entitled miserable, explosive feeling-fest.

    Due to such cycles of binging “decency causes abuse”. And since decency thrives on “logic” it will in future try to persuade the masses that it is “logical” that children like to be bullied and abused by such entitled demanders.

    The bullies will persuade children that they must learn to give “perfect love”. The love that lets the bully get away with anything. The bully will do so because the bully cannot take responsibility for their own lack of love towards themselves. They must demand it and coerce it and force from another as if it is their right. Their sense of entitled right then comes up against a child’s basic HUMAN RIGHT not to be abused.

    A fear is that in future adolescents who are growing up with this paradigm of entitlement are going to confuse it for real love. And punish younger siblings for not granting it.

    They will say abuse is “natural”.

    Parents should NEVER abuse. Offspring should NEVER abuse other offspring. Nobody on planet Earth should EVER be abused.

    Psychotherapy must clear up its muddles.

    The best way forward is if everyone gets better at realizing what BALANCE means.

    If a bully is pushy it is because they are imbalanced within, living in a state of disconnect from that which would produce empathy and compassion. Feelings.

    Why people take flight from their feelings is because their feelings are not allowed in a linear civilization. But going around as a “logical” entitled demander is no way to get your inner being full of YOUR own feelings. Rather it is asking others to be your feelings for you, a siphoned in supply chain. To that you may become an addict.

    An addict will do anything it takes to find their “fix”.

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  5. The therapy room often serves as a staging ground for colonization. The minds of the subjugated other: the last unconquered territory.

    “Wow you are very well spoken”
    “But this is America”
    “You know, this asian american political scientist said identity politics is divisive”

    -Actual therapist

    Translation: The dominant class should be free to racialize and otherize me, but I should not politicize the fact that I am being categorized differently.
    (Frances Fukuyama is a realpolitik neo-con of the Reagan and W. Bush administrations, famously one of the forty signatories on a letter calling for war against Iraq)

    Bonus: speak with praise and envy of indigenous culture, but through a lens of exoticism and fetishization, speak as if they are extinct, and reject contemporary social practice of such values as unamerican.

    Extra credit: demand seamless assimilation from second-generation inheritors of multicultural legacies while referring to these natural born citizens as immigrants in the same breath.

    Extra, extra credit: Blame institutionalized prejudice on the targeted demographics through endless articles expounding on minority populations for having “stigma” against mental healthcare, for being prejudiced against psychic ailments, for collective ignorance of “science”.

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