Racial minority clients’ experiences of sociocultural issues in psychotherapy.

BackgroundGender minority populations experience an increased risk of depression and report significant barriers to accessing mental health services. While digital mental health (DMH) technologies may address barriers, it remains unclear how gender minority clients engage with DMH services and if DMH improves their clinical outcomes.ObjectiveThis naturalistic study explored gender differences in 15-week clinical outcomes of clients receiving technology-mediated psychotherapy from a large DMH provider.MethodsThis study used observational data of clients who signed up for Talkspace (Talkspace, Inc) between February 2017 and July 2021. The analytic sample included Talkspace clients (N=20,156) with a baseline 8-item Patient Health Questionnaire (PHQ-8) score ≥10. Participants completed at least 2 PHQ-8 assessments over 15 weeks of treatment. Multilevel linear models tested gender differences in depressive symptom trajectories over the course of treatment (model 1) while also controlling for baseline PHQ-8 scores (model 2) and treatment engagement indicators (model 3). Sensitivity analyses reestimated model 2 among clients who submitted a PHQ-8 survey during the week 15 assessment period and among those who discontinued treatment beforehand. Reasons for service cancellation were also described for the latter group. Gender differences in secondary clinical outcomes were examined via chi-square and Fisher exact tests.ResultsIn all models, there were significant week-by-gender interactions. When controlling for baseline PHQ-8 scores, rates of symptom change were significantly slower for gender-diverse participants (b=0.60; P<.001), nonbinary participants (b=0.81; P<.001), and transgender women (b=0.87; P=.007), but not for women (P=.98) or transgender men (P=.38) compared to men. By week 15, adjusted PHQ-8 scores declined 8.7 points for both men and women, versus 4.4‐7.4 points for gender minority clients. Sensitivity analyses indicated attenuated symptom improvement among week-15 completers, with transgender women showing the slowest changes (b=0.76; P=.02). Among earlier dropouts, weekly symptom reductions were steep overall (eg, week 3: b=−4.06, P<.001; week 6: b=−2.31, P<.001) while certain gender minority subgroups worsened (eg, adjusted scores for transgender women increased from 15.41 at baseline to 16.08 at final week 3 PHQ-8 survey submissions). Cancellation data (3450/20,156, 17.12%) confirmed discontinuation reasons related to both symptom improvement (928/3691 reasons, 25.14%) and potential barriers to treatment engagement (eg, cost: 1431/3691, 38.77%; poor service fit or poor perceived effectiveness: 677/3691, 18.34%). Gender differences were observed in rates of treatment response (weeks 3‐12; all P≤.02), symptom remission (weeks 3, 6, 9, and 15; all P≤.047), and clinically significant symptom reduction (all time points, all P≤.03). Symptom deterioration did not differ by gender (all P>.05).ConclusionsWhile clinical outcomes generally improved over time among clients engaged in technology-mediated psychotherapy, some gender minority populations experienced slower improvements. Future research may explore strategies to adapt DMH interventions to better meet the needs of diverse gender identities.

Background/Objectives: Integrating behavioral health and primary care services is a national public health priority in the US, especially in underserved settings like northern Arizona. This healthcare delivery model is crucial to meet the mental and physical health needs of people with SU/SUDs, particularly those belonging to culturally diverse populations. In collaboration with a behavioral health center in northern Arizona, the current study aimed to assess the perspectives of providers and administrative staff on the implementation of integrated primary care (IPC) services for people with SU/SUDs. Methods: In February 2023, twelve healthcare providers and administrative staff from diverse educational backgrounds were recruited using purposive sampling to capture a range of perspectives on IPC implementation at the behavioral health center. Participants completed individual, semi-structured interviews conducted via Zoom, which were audio recorded and lasted approximately 30 min. The interview recordings were transcribed verbatim using Trint Software, and analyzed on Google Docs using applied thematic analysis. Two researchers coded the transcripts, iteratively developing and refining themes through multiple cycles of review and team discussions. Additional team members provided feedback and verified the themes, with consensus reached through collaborative meetings. This rigorous, iterative approach ensured the reliability and validity of the final thematic framework. Results: We found that IPC supports SU/SUDs recovery by providing holistic care that integrates medical, mental health, and addiction services while addressing social and co-occurring needs. It fosters an empathetic environment where clients do not need to repeatedly disclose their SU/SUDs, improves access to preventive care, and offers continuous support and education. Implementation barriers included workforce shortages, limited internal communication, and insufficient interdisciplinary training. Gaps in culturally centered care were identified, including reliance on Western models, limited representation of Native American and sexual and gender minority staff, and inconsistent use of inclusive practices such as pronouns, traditional healing, and trauma-informed approaches. Additionally, community partnerships with multisectoral organizations help clients access supportive resources beyond the facility, including vision care, clothing, and dental services. Conclusions: The implementation of IPC was seen as important to support the behavioral health center in northern Arizona to foster an empathetic environment where clients with SU/SUDs can have their mental, physical, and social needs addressed, either within the facility or through community partnerships, thereby supporting their recovery. However, progress is hindered by barriers such as workforce shortages, limited internal communication, and insufficient interdisciplinary care training. Additionally, despite regular cultural competency training, gaps remain in culturally centered care for underserved populations, particularly Native American and sexual and gender minority clients.

Minority clients’ self-confidence is often influenced by various obstacles that arise within the context of multicultural counseling. These obstacles can be internal or external, including experiences of discrimination, social prejudice, language differences, and conflicts related to cultural identity. Counselors who are not sensitive to clients’ cultural and social dynamics risk reinforcing low self-confidence and hindering the counseling process. This study aims to analyze these barriers and identify effective intervention strategies to enhance minority clients’ self-confidence. The method used is a comprehensive literature review of studies related to multicultural counseling, self-esteem, and empowerment of minority clients. The analysis shows that culturally-based counseling approaches, adaptive communication, and the application of empowerment techniques can help clients overcome psychological and social barriers. Additionally, creating an inclusive and emotionally safe counseling environment has been proven to increase client engagement and strengthen self-confidence. This study emphasizes the importance of multicultural training for counselors and the implementation of strategies that respect clients’ cultural identities. The findings provide practical implications for counselors to develop effective interventions that support the psychological well-being of minority clients.

Client diversity is a cornerstone of blockchain resilience, yet most networks suffer from a dangerously skewed distribution of client implementations. This monoculture exposes the network to very risky scenarios, such as massive financial losses in the event of a majority client failure. In this paper, we present a novel framework that combines verifiable execution and economic incentives to provably identify and reward the use of minority clients, thereby promoting a healthier, more robust ecosystem. Our approach leverages state-of-the-art verifiable computation (zkVMs and TEEs) to generate cryptographic proofs of client execution, which are then verified on-chain. We design and implement an end-to-end prototype of verifiable client diversity in the context of Ethereum, by modifying the popular Lighthouse client and by deploying our novel diversity-aware reward protocol. Through comprehensive experiments, we quantify the practicality of our approach, from overheads of proof production and verification to the effectiveness of the incentive mechanism. This work demonstrates, for the first time, a practical and economically viable path to encourage and ensure provable client diversity in blockchain networks. Our findings inform the design of future protocols that seek to maximize the resilience of decentralized systems.

Cultural humility, knowledge, and identity salience when working with sexual and gender minority clients.

Supplemental Material for Cultural Humility, Knowledge, and Identity Salience When Working With Sexual and Gender Minority Clients

Increasing HIV testing among priority populations is a primary strategy of the Ending the HIV Epidemic initiative. In October 2019, the Philadelphia Department of Public Health (PDPH) established a program to distribute publicly-funded HIV self-testing (HIVST) kits to Philadelphia County residents aged 16 years and older. Through a community-academic partnership, we used a cross-sectional sequential transformative mixed-methods design to examine perceived organizational factors, opportunities, and challenges to HIVST integration among agency staff at PDPH-funded agencies early in the COVID-19 pandemic due to decreased access to traditional in-person HIV testing services with a focus on agencies whose client populations included sexual and gender minority clients assigned male sex birth aged 13 to 24 years (not the sole population served at each agency). We integrated data from online surveys conducted with HIV testers (test counselors and testing leads), agency leaders (agency leads and directors), and care navigators (n = 42), and semi-structured interviews with HIV testers and agency leaders (n = 11) employed at PDPH-funded agencies. Many staff were familiar with HIVST (79%), and approximately two-thirds (64%) were likely to encourage HIVST to clients. In interviews, perceived benefits of HIVST integration were increased access to HIV testing, accommodation for client privacy, decreased risk of stigmatizing encounters, and testing program adaptability. Perceived challenges were loss of connection with clients, suboptimal linkage to HIV treatment and prevention services after self-testing, concerns regarding clients' correct use or interpretation of test results, and client preference. Agency staff described HIVST as a useful tool for expanding low-barrier HIV testing services; however, staff foresaw potential implementation challenges. To optimize HIVST as a long-term strategy, resources are needed to increase familiarity and comfort with HIVST and enhance staff's capacity to establish meaningful client connections and link clients to post-test HIV treatment and pre-exposure prophylaxis services.

Introduction Previous research has demonstrated that concealment of a minority sexual orientation is correlated with poorer mental health. Impostor phenomenon may mediate this link. This is the first study to empirically examine impostor phenomenon among sexual minority adults. Method Five hundred and ninety-nine sexual minority adults (M age = 27.62) were recruited through social media advertisements and snowball sampling. Participants completed an online survey assessing concealment, impostor phenomenon, depressive symptoms, anxiety symptoms, and internalized homonegativity. Results Consistent with previous research, concealment predicted both depression and anxiety. Impostor phenomenon meditated the association between concealment and depression and concealment and anxiety. However, internalized homonegativity did not moderate the associations between concealment and mental health outcomes or concealment and impostor phenomenon. Conclusion This study fills an important gap in the literature by introducing the construct of impostor phenomenon to the field of sexual minority mental health. When working with sexual minority clients, therapists should ask about their clients’ concealment behaviors and experiences with impostor phenomenon.

Vocational interests are an important factor in individuals' career choice and development. However, current understanding about the vocational interests of sexual minorities is underdeveloped. Using data from 31,348 men and 59,715 women (N = 91,063) from 48 countries who self-identified as heterosexual, gay/lesbian, bisexual, or asexual, this study used a fine-grained approach to investigating the relationship of sexual orientation to Holland's realistic, investigative, artistic, social, enterprising, and conventional interests, separately by gender. Across these countries, we also explored how the strength of social norms-that is, cultural tightness-looseness-moderates this relationship. Results indicated generally small sexual orientation differences in realistic, investigative, artistic, social, enterprising, and conventional interests within women and within men. On average, the interests of sexual minorities tend to be less gender-typical, but more investigative and artistic, than those of heterosexual people. Multilevel analyses show that cultural tightness-looseness moderated sexual orientation differences in realistic, investigative, artistic, social, enterprising, and conventional interests, such that some of these differences are smaller (larger) in tight (loose) cultures. This implies that tight cultures that have strong norms might constrain sexual minorities' vocational interests, whereas loose cultures that have weak norms offer greater latitude for them to pursue different interests. Altogether, this study advances our collective understanding of sexual minorities' vocational interests and highlights the role of the cultural context in shaping their career choices and development. Implications for counseling and career development of sexual minority clients are discussed. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

ABSTRACT Transgender youth are disproportionately affected by HIV, particularly minoritized youth in the US south. To understand HIV service use among transgender youth, we interviewed 25 young racial and ethnic minority clients of four southern community-based HIV service organizations (CBOs), and CBO staff (n = 12), about service access and use. Participants were assigned male at birth and identified as female (n = 8), transgender (n = 11) or gender-fluid or nonbinary (n = 6). The majority were Black/African American or mixed race; four were Hispanic or Latino/a. Most were unemployed; nearly half were unstably housed or homeless during the prior year. Four service types were each used by approximately two-thirds of participants: counseling/support, HIV/STD testing/education, pre-exposure prophylaxis education/prescriptions, and transgender-related medical services (primarily hormone provision). Just over a quarter used social services (e.g., housing, employment). Key facilitators to service use included a non-stigmatizing CBO atmosphere, and easy and convenient access. Poor access (e.g., inconvenient hours, location), lack of transportation or parking, social service needs, and lack of money were barriers. Qualitative reports highlighted unmet social service needs, particularly housing, especially for those without HIV. To reduce disparities, HIV prevention for racial and ethnic minoritized transgender youth should simultaneously address hormone provision, HIV risk reduction and social service needs.

Proposed Self-as-Context Interventions for Gender Minority Clients

Personal therapy is a common mandatory element of counseling and psychotherapy training in the United Kingdom. Previous research has established that this practice provides trainees with a unique learning space but also is associated with financial and emotional costs. Furthermore, some argue that the practice of personal therapy is ethically questionable. At the heart of many relational modalities, such as Gestalt psychotherapy, lies the relationship between client and therapist and more research is needed to explore how trainees perceive established training methods. The current study recruited 11 trainee Gestalt practitioners and conducted one-to-one semi-structured interviews to explore their experiences of engaging in personal therapy. A number of themes emerged in reflexive thematic analysis: trainees perceived personal therapy to be associated with professional and personal gains as well as financial and emotional costs; they also viewed personal therapy to be an essential component of their training but would like to be involved in discussions around how it is shaped. We recommend that training providers and professional bodies offer such a dialogic space, and that future research and practice further considers the barriers of minority clients and trainees in particular.

Abstract The ways in which minority street-level bureaucrats construe their identities as state representatives and as representatives of minority clients are known to inform their discretionary behavior toward clients, thereby shaping policy outcomes. While existing studies have examined race and ethnicity as shared identities between minority bureaucrats and clients, the role of “migrant” identity has been overlooked. Focusing on the so-called European migration crisis of 2015–2017, this study addresses this gap. Drawing on qualitative interviews with migrant bureaucrats, it examines how being simultaneously a migrant and a migration policy implementer shapes bureaucratic discretion. This article introduces the notion of “migrant representative” and identifies four profiles of migrant bureaucrats, each corresponding to different degrees of identification with the local migration management system and the migrant clients. In doing so, it contributes to the literature on representative bureaucracy and the debate on the linkage between passive and active representation.

Sexual minority clients report experiencing frequent microaggressions during therapy, however, therapists may not recognize those microaggressions or may be reluctant to self-report them. The main aim of the present study was thus to develop an observational measure of in-session therapist-committed microaggressions related to the sexual orientation of sexual minority individuals (e.g., those who identify as lesbian, gay, bisexual, or queer). The present study further examined the association between therapist-committed sexual orientation microaggressions and ruptures in the therapeutic alliance. We hypothesized that clinically significant microaggressions would be positively associated with withdrawal ruptures in the alliance. The sample consisted of 44 gay and bisexual men who participated in a cognitive behavioral treatment designed to reduce depression, anxiety, human immunodeficiency virus-transmission-risk behaviors, and substance use. An observer-based coding measure designed for this study, the Sexual Orientation Microaggression Rating Scale (SOMRS), was utilized to capture sexual minority microaggressions in the initial sessions of treatment. Good interrater reliability was achieved for the SOMRS. Microaggressions were coded in 34% of the sessions. Within the subset of sessions with coded microaggressions, a significant association was found between withdrawal ruptures and microaggression significance ratings. The SOMRS holds potential for supporting research on microaggression as well as future efforts to help clinicians recognize and repair in-session behaviors that negatively impact sexual minority clients. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

How Can Sexual and Gender Minority Latter-day Saints Resolve Identity Conflict and Improve Their Mental Health? Results From a 2- to 4-Year Longitudinal Study

ABSTRACT Boundaries are a practice of separating one thing from the other; to make clear where I end and where you begin. Establishing and enforcing clinical boundaries is taken for granted as a necessary foundation of therapeutic work by social work’s governing and administrative bodies. Upon interrogation, normative standards of ethical practice tend to serve broader populations and institutions by deputizing social workers to self-police, even as such boundary norms may fail to serve the individuals and relationships at the heart of clinical practice. As a collective of early-career clinical social workers, we have at times felt certain obligatory boundaries force us to choose between serving an institution and caring for an individual. We explore moments where tension between boundaries and care is felt in vignettes from our clinical work with queer, trans, and racial minority clients, and through our analysis of boundary-setting texts. Seeking to queer norms of boundary-making discourse, we explore the possibilities of resistance that empower clients and prioritize relationships.

Abstract AimBlack queer men in the UK are increasingly at risk of mental health problems related to anxiety and depression, often triggered by traumatic experiences. This study explored the efficacy of integrative practice with Black queer men who experienced trauma from a decolonised, intersectional and queer‐affirming perspective.MethodOne‐to‐one semi‐structured interviews with nine integrative practitioners were completed. Data collected from these interviews were analysed using Braun and Clarke's six stages of reflexive thematic analysis (RTA).FindingsRTA identified four subordinate themes: (1) understanding the experience of Black queer men, (2) developing the working alliance and use of self in practice, (3) effective integrative practice and (4) intersectional differences and considerations. Findings discussed the varying forms of trauma Black queer male clients experienced that impacted their mental health and how developing a strong working alliance with Black queer men was crucial when supporting them to recover from trauma. Additionally, the participants described a breadth of trauma‐informed integrative counselling and coaching practice. A decolonised approach utilising the intersection of race, gender and sexuality of Black queer men was successfully integrated into the approach used by practitioners in this study.ConclusionOverall, this study evidenced that a decolonised perspective to integrative practice effectively supports Black queer men to recover from trauma. Future research should focus on an integrated approach with Black queer men and other gender and sexual ethnic minority clients who experienced trauma.

Abstract Literature suggests LGBTQ+ cultural competencies and cultural humility as critical components to providing counseling services to LGBTQ+ clients. Previous research has shown that cultural humility leads to better counseling outcomes through the counseling alliance in sexual minority clients. This study investigated the relationships among cultural humility, counseling alliance, and counseling outcome among 584 LGBTQ+ counseling clients (38.5% were non‐cisgender). The results revealed that all three constructs were positively related to one another. Counseling alliance mediated the relationship between cultural humility and counseling outcome. The overall mediation model indicated that cultural humility had direct and indirect effects accounting for 58% of the variance in counseling outcome when controlling for gender, sexual orientation, and level of education. The findings underscore the importance of cultivating cultural humility among counselors working with LGBTQ+ clients to improve counseling alliance and counseling outcomes.

Culture is a significant factor in human development, sustainability, and societal cohesion. It is greatly cherished and holds universal significance to individuals, groups, families, communities, societies, and nations. Culture affects how a victim, survivor, client, or family responds to life altering experiences such as domestic violence, child abuse and neglect, sexual abuse, and trauma. It also influences how a client or family deals with loss and grief, resilience, and recovery. Hence, understanding different cultures and cultural practices, symbols, artifacts, the meaning they hold, and respecting and operating within the confines of a set culture is very important. Cultural competency is a key medium through which this need can be addressed. Cultural competency is a core principle that should undergird a social worker’s service/practice with clients as enshrined in the Code of Ethics of the National Association of Social Workers. Failure to execute cultural competency is detrimental to the delivery of appropriate and effective services to clients, and a digression from the code of ethics and professional standard of practice within the profession of social work. The execution of cultural competency in social work practice fosters a positive and enduring therapeutic relationship between the social worker and client, and lays the foundation for productive engagement, interaction, and intervention. From this perspective, this article embodies a review of the research literature on the topic of culture and culturally competent practice from different disciplines. The review and analysis include a study this author conducted in Ghana-Africa that examined the significance of culture and its impact on individuals and their perceptions as well as behaviors within a cultural context. Specifically, the study focused on the cultural effects on learning and the transfer of knowledge, and this paper relates its significant implications for understanding culture and responsiveness to cultural practices within professional practice. The findings from this original study revealed that culture impacts an individual’s perception and behavior significantly. The implications for culturally effective social work practice were discussed and recommendations for cultural competence, responsive, and responsible practices including anti-oppressive intervention strategies at the micro, mezzo and macro levels were put forward. In addition, a cultural conceptual practice model called GACIE was proposed for use in assessing and intervening with culturally diverse ethnic minority clients.