Effects of Gender, Race and Age Matching on Client Ratings of the Therapeutic Alliance

Identity matching between therapists and clients has been shown to affect the processes and the outcomes of psychotherapy. A quasi-experimental study will be conducted in which patients (n=300) in identity matched or identity mismatched therapeutic pairs will report their perception of the therapeutic alliance and their therapists’ engagement with multicultural orientation framework (MCO) variables. This study is expected to find that matching by gender, matching by race, and matching by age are all significantly correlated with participant ratings of the therapeutic alliance, such that matching predicts higher ratings of the therapeutic alliance across treatment. The results of this study will also show that client ratings of MCO variables will correlate positively with higher ratings of the therapeutic alliance. The results will also show that clients in matched therapeutic dyads will rate their therapeutic alliance higher across sessions compared to clients in mismatched therapeutic dyads. These results suggest that matching by identity characteristics including race, gender and age is a predictor of the quality of the relationship between therapist and client, and that this is a potential way to improve therapeutic treatment, especially for clients from historically marginalized identity groups. IDENTITY MATCHING AND THERAPEUTIC ALLIANCE 3 Effects of Gender, Race and Age Matching on Client Ratings of the Therapeutic Alliance Psychotherapeutic treatment is intended to be a safe and comforting space for individuals to receive help and support from a mental health professional. However, this is not always the case, especially for racial and ethnic minority patients. For instance, 53-81% of clients in psychotherapy reported experiencing at least one microaggression during treatment (Hook et al, 2016). Some studies have also shown better therapeutic outcomes for White patients in comparison to racial and ethnic minority patients (Drinane et al., 2016; Imel et al., 2011). Prior research has also shown that older patients are perceived as sicker and less treatable than younger patients, and that therapists often are more willing to treat younger patients (Karasu, 1979). Despite the professionalism required of psychotherapists, implicit and explicit race, gender, and age biases are still present, and can affect therapists’ working relationships with their patients (Boysen, 2011; Hansen et al., 2019). Matching these aspects of identity between clients and their therapists has been shown to be useful in improving therapeutic outcomes for clients in marginalized identity groups. There is a relatively large body of research on the effects of identity matching between therapist and client on process and outcome variables of psychotherapy, and while research is divided on the effects, it is possible that identity matching can improve therapy outcomes for patients, including racial and ethnic minority patients, older patients, and patients of all genders, through improvement of the therapeutic alliance (Farsimadan et al., 2006; Flicker et al, 2008; Wintersteen et al., 2005). The value of the alliance between therapists and clients is vital to effects of identity matching. The therapeutic alliance is a concept which originates from the psychodynamic psychotherapeutic concept of transference, wherein the patient transfers and projects their interpersonal feelings about individuals in their life onto their therapist, and a psychotherapist IDENTITY MATCHING AND THERAPEUTIC ALLIANCE 4 can use this to gain understanding of their patient and effectively treat them. Defined as the working relationship and collaboration between the therapist and the client (Ardito & Rebellino, 2011), the therapeutic alliance creates a dynamic system of interaction, providing therapists with essential understanding of their patient, and providing patients with an interpersonal connection in which to contextualize their treatment. The alliance is often considered to be the strongest predictor of client change during psychotherapy (Horvath et al., 2011; Wampold, 2001). This alliance can be affected by the interpersonal capacity of the patient, such as trauma associated with a parent and by interpersonal dynamics, the patient’s will to change, as well as by the demographic characteristics of the therapist and client (Cheng & Lo, 2018; Karasu, 1979). A mediator of the effects of identity matching is the similarity-attraction theory, which suggests that individuals like others who are more similar to them physically and attitudinally (Byrne, 1961). This applies to all interpersonal relationships, including the therapeutic alliance. Similarity within the therapeutic alliance can potentially lead to a more successful therapeutic alliance, more effective therapy, and less instances of bias-based microaggressions. Cultural incompetence in mental health treatment is common, especially in cross-cultural dyads (Vasquez, 2007). Microaggressions and unintentional bias from privileged clinicians can invalidate positive effects of treatment for clients of historically less privileged groups, including racial and ethnic minority clients, women, and the elderly (Chrisler et al., 2016; Pieterse et al., 2012). Matching between therapists and clients along such identity characteristics as race, gender and age is a possible solution to this issue, but it has been researched with mixed results. While some research supports a connection between identity matching and positive experience of therapy (Johnson & Caldwell, 2011; Tall & Ross, 1991; Wintersteen et al, 2005) other research studies reports opposing results (Behn et al., 2018, Zlitnick, 1988). Across the literature, specific IDENTITY MATCHING AND THERAPEUTIC ALLIANCE 5 focus on the impact of matching on the quality of the therapeutic alliance is lacking, especially in studies on race and ethnic matching and on age matching. The majority of the current literature on matching does not take into account variables in therapist training and execution of treatment. This study aims to offer new insight into identity matching and the therapeutic alliance in the context of the Multicultural Orientation Framework, in pursuit of improving the process and outcomes of psychotherapeutic treatment for all. Similarity-Attraction Theory Better appreciation of the effects of client-therapist match with respect to race, gender, and age can be gained from an understanding of the Similarity-Attraction Theory (Byrne, 1961). Specifically, this theory indicates that perceived physical similarity between individuals increases the likelihood that they are attracted to each other affectively, cognitively, and behaviorally (Michinov & Montiel, 2002). Attitudinal similarity has also been shown to increase interpersonal attraction between individuals (Byrne & Nelson, 1965). Recent studies building on Byrne’s work have found stronger effects of dissimilar attitudes than similar attitudes on opinion of others, such that attitudinal dissimilarity between individuals is strongly predictive of a lack of attraction (Singh & Tan, 1992). Applied to psychotherapy, this may suggest that when therapists and clients are similar in terms of identity characteristics, including gender, race, and age, the alliance and the relationship between the two parties may benefit, and when therapists and clients differ in such identity characteristics, the therapeutic alliance suffers. Since the Similarity-Attraction theory’s inception researchers have sought to demonstrate its efficacy. Montoya and Horton (2012) investigated the two potential explanations for the similarity-attraction effect. They conducted a meta-analysis of 240 laboratory studies on the effect, and found support for the information processing model, which suggests that individuals IDENTITY MATCHING AND THERAPEUTIC ALLIANCE 6 base their opinion of others on how the information they know about others compares to their own attributes, which are used as the baseline for positive attributes. Study results show that when personal attributes are rated positively, others who share those attributes are seen positively as well. These findings are supported in additional similarity literature, with children, for instance, preferring other children or representations of children who had appearances similar to their own (Fawcett and Markson, 2010). Furthermore, people may be more likely to sit near to individuals who have similar physical characteristics, due to perceived attitudinal similarity (Mackinnon et al., 2011). Taken together, these findings suggest that similarity mediates a sense of shared experience and worldview, which may facilitate interpersonal connections in the context of psychotherapy. Race, gender, and age are all key components of identity. Attitudes which are assumed from those identity characteristics have been shown to strongly influence liking and interpersonal attraction (Byrne, 1997; Singh et al., 2007). The demographic characteristics of therapist and client have also been shown to impact the therapeutic alliance (Cheng & Lo, 2018). Therefore, in therapist patient pairings which are matched on gender, race, or age, perception of attitudinal similarity based on shared identity characteristics will lead to a stronger therapeutic alliance.