Barriers and Facilitators in Discussing Race and Racism with Youth: Overcoming Passivity and Building Confidence

Abstract

Objective:

This study examined youth-serving community mental health clinicians’ multicultural counseling knowledge and awareness and their perceived barriers and facilitators in discussing race and racism with clients. Additionally, the study explored how clinicians’ knowledge and awareness were related to their reports of barriers and facilitators in addressing race and racism.

Methods:

The current study is a mixed-method study of 119 youth-serving community mental health clinicians across Washington State. We explore qualitative themes in clinicians’ reports of perceived barriers and facilitators in broaching topics of race and racism. We also examine if reported barriers and facilitators correlate with the Multicultural Counseling Knowledge and Awareness Scale.

Results:

Qualitative themes emerged at the client-, clinician-, organizational-, and societal-levels. Barriers included clinicians not engaging in racism-related discussions unless clients initiated them, clinicians’ discomfort or lack of confidence, and clinicians’ perceptions of harm or limitations because of their racial identification. Clinicians were more willing to broach topics of race or racism with older clients, with stronger perceptions of rapport, and when topics were broached earlier in therapy. There was no statistically significant correlation between the count of perceived barriers or facilitators and clinicians’ multicultural counseling knowledge and awareness.

Conclusion:

Qualitative and quantitative data highlight considerations for assessing and supporting clinicians’ cultural humility. Enhancing multicultural competency and humility can help clinicians recognize their strengths and limitations, fostering a deeper understanding of clients’ cultural backgrounds. Encouraging clinicians to facilitate open discussions about race and racism is a key step in this process.

Introduction

There are persistent mental health inequities, evidenced by higher levels of specific mental health conditions and challenges in accessing quality care among racially and ethnically minoritized populations (Alang, 2019; Rodgers et al., 2022). Many factors, including systemic racism, drive these inequities (Pieterse et al., 2023) and are evident in the care provided to racially minoritized clients today. Systemic racism refers to how systems, including health systems, reinforce racism through “the complex array of anti-Black practices, the unjustly-gained political-economic power of Whites, the continuing economic and other resource inequalities along racial lines, and the White racist attitudes created to maintain and rationalize White privilege and power” (Feagin JR, Ducey K. Racist America. New York (NY): Routledge; 2018; p. 6). Systemic racism drives inequities through mechanisms that constantly expose marginalized populations to discriminatory practices, economic disadvantages, and social exclusion, which lowers their sense of self-worth, and psychological adjustment (Kelaher et al., 2018), increases their risks for mental health disorders like anxiety and depression (Braveman et al., 2022; Pieterse et al., 2023).

Despite the well-documented impacts of racism on client’s mental health, clinicians may lack knowledge or training in how to sensitively and humbly discuss race and/or racism with clients. Clinicians’ racial biases, when left unchecked, can manifest as behaviors that reinforce racial stereotype threat, creating a negative feedback loop that worsens patient outcomes and leads to higher rates of premature treatment termination, which may contribute to further inequities (Ray, 2022; Van Ryn et al., 2011). For instance, clinicians with high implicit and low explicit biases often exhibit less eye contact and closed posture, which Black clients interpret as deceitful and have decreased satisfaction and trust in the clinician, further hindering effective care (Van Ryn et al., 2011).

Anti-Racism and Cultural Humility in Clinical Practice

Scholars have advocated for incorporating an anti-racism framework in mental health research and practice, which recognizes systemic racism and involves actively dismantling oppressive structures to improve minoritized clients’ well-being through race-based competencies and social change (Galán et al., 2021; Jones & Branco, 2023). Examining the impact of racism on mental health, particularly when clients and clinicians do not share the same racial identification, requires an anti-racist approach that includes not only acquiring multicultural counseling competence but also fostering cultural humility. The tripartite model of multicultural counseling competence includes clinicians recognizing their values and beliefs related to race and ethnicity, developing their knowledge related to different worldviews and experiences, and identifying and honing skills to work with clients of color (Sue et al., 1982, 1992; Wilcox et al., 2022). Clinicians’ self-reported multicultural counseling competency has been associated with various treatment processes and outcomes, such as therapeutic alliance, client satisfaction, and symptom reduction (Penn & Post, 2012; Neville et al., 2006; Soto et al., 2018; Tao et al., 2015). However, recent studies also indicate that self-reported competency may not correlate with treatment outcomes as strongly as client-rated multicultural competence, which highlights a gap in existing measures (Zhu et al., 2022) and calls for greater exploration of other constructs related to multicultural competence.

Related to multicultural competence, though thought by many to be distinct, is the concept of cultural humility—a continual process of self-reflection and learning to explore and challenge one’s cultural biases (Hook et al., 2017; Zhu et al., 2023). Integrating both competence and humility, anti-racist care not only requires that clinicians be competent in multicultural counseling skills and maintain awareness of common multicultural counseling frameworks and myths but also continually engage in self-reflection and exploration. Practicing clinically with cultural humility, beyond competence alone, requires that professionals challenge systemic racial biases, constantly self-reflect, and advocate for culturally sensitive care (Owen et al., 2016; Jones & Branco, 2023). Cultural humility also requires that clinicians invite their clients to discuss race and racism in session, which not only signals their ability to discuss the concepts but also provides an opportunity for clinicians to learn from their clients about their experiences. By holding conversations about race and racism with cultural humility, clinicians may build stronger alliances with clients, potentially addressing premature treatment termination and addressing, at least in part, systemic biases that contribute to mental health inequities (Corneau & Stergiopoulos, 2012; Rovitto, 2022).

Cultural Humility in Community Mental Health

Community mental health (CMH) is among the most accessible care systems in the United States. It serves a diverse population with high needs and minimal resources (Mongelli & Pato, 2020). CMH clients are generally more varied across the multicultural spectrum of racial or ethnic heritage, gender, age, religious orientation, and housing status, among other dimensions of cultural identity (Delphin & Rowe, 2008). Given the populations and areas in which they practice, CMH clinicians are critical agents in facilitating access and improving culturally responsive services for marginalized clients (Weaver & Lapidos, 2018), including exploring the impacts of race and racism in their clients’ lives. As such, youth-serving CMH clinicians also play a crucial role in facilitating discussions of race and racism, promoting an inclusive and supportive environment that significantly impacts youth at the developmental stage of forming racial identity (García Coll et al., 2018). However, there is limited research on multicultural competence or humility within CMH clinicians, including the extent to which clinicians feel comfortable engaging in conversations regarding race or racism or choose to avoid them. As such, work is needed that characterizes both these constructs (i.e., multicultural competence and cultural humility). Additionally, by examining knowledge and awareness (i.e., aspects of competence) in conjunction with self-reported barriers and facilitators to discussing race and racism (i.e., aspects of cultural humility), we can gain greater insight into clinicians’ cultural humility and how it may (or may not) be related to multicultural counseling knowledge and awareness. This can inform future measurement and intervention. Understanding CMH clinicians’ multicultural competence and humility may help inform efforts to increase clinicians’ awareness of their own biases (Schouler-Ocak et al., 2021) and target training to facilitate conversations about race and racism. Examining the factors impacting discussions of race and racism may help to improve the quality of care provided to racially and ethnically minoritized clients, thereby improving mental health equity.

Current Study

Although some research has studied the efficacy of clinician’s multicultural counseling knowledge and awareness (Jones & Lee, 2021; Soto et al., 2018), limited research focused on CMH clinicians. As such, we sought to describe youth-serving CMH clinicians’ multicultural counseling knowledge and awareness using a validated scale. Further, guided by theory on anti-racist clinical practice and cultural humility, we examined CMH clinicians’ perceived barriers and facilitators to discussing race and racism with clients. The current study’s quantitative component aims to generate generalizable scores on clinicians’ knowledge and awareness, while the qualitative component seeks to capture clinicians’ humility, self-reflection, and sensitivity to cultural encounters with minoritized clients. The qualitative measure thus serves as a critical supplement, providing a more comprehensive view of clinicians’ practices when working with minoritized youth. The ultimate goal of the study was to inform future training and support for clinicians to discuss these topics with their racially and ethnically minoritized clients (Triplett et al., 2023).

Method

Participants

Participants were 119 youth-serving community mental health clinicians and supervisors across Washington State. Participants were primarily recruited from an email list of nearly 2,000 clinicians participating in a Washington State-funded evidence-based practice training initiative (Dorsey et al., 2016). Members of the email list were willing to receive and consider research opportunities. Clinicians were encouraged to share the study with colleagues not on the email list. To be eligible for participation, participants were required to be working in a community mental health clinic.

Procedures

All data was collected via a secure online survey. Participants were directed to an anonymous survey to respond to quantitative and open-response qualitative measures. Participants received a $25 gift card to complete the survey. The University of Washington Institutional Review Board reviewed all study procedures and determined it exempt from review.

Measures

Barriers and facilitators of discussing race.

Short answer questions were administered to gather clinicians’ perceptions of the barriers and facilitators of discussing race and racism with clients. To determine facilitators of discussing race and racism, we asked: “What makes it more likely that you address race with your Clients of Color (e.g., Black, Indigenous, Latino, Asian)?” To determine barriers to discussing race and racism, we asked: “Have there been times when you chose not to address race with your Clients of Color (e.g., Black, Indigenous, Latino, Asian)? Why did you choose not to address race? What thoughts or feelings did you have that prevented you from addressing race?” Questions were free response with no character limit.

Multicultural counseling knowledge and awareness scale (MCKAS-R).

To measure clinicians’ multicultural counseling competencies, clinicians responded to the self-report Multicultural Knowledge and Awareness Scale (MCKAS-R; Lu, 2016). The MCKAS-R is a 28-item, 7-point Likert-type (“1” = not at all true to “7” = totally true) scale that is designed to assess a clinician’s self-perceived multicultural counseling competence in working with racially and ethnically minoritized clients (Lu, 2016). The measure examines two domains: Knowledge (17 items, possible range of scores = 17 to 119) and Awareness (11 items, possible range of scores = 11 to 77). The knowledge domain examines general knowledge about multicultural counseling, with higher scores indicating greater knowledge. The awareness domain explores clinicians’ worldview bias, with a lower score meaning more awareness of the process of awakening, knowing, and being conscious of clinicians’ attitudes and beliefs. The MCKAS-R has acceptable internal consistency, with the validation study reporting Cronbach’s alpha being 0.89 for the knowledge subscale, 0.86 for the awareness subscale, and 0.90 for the entire scale. In our sample, Cronbach’s alpha was 0.88 for the knowledge subscale, 0.81 for the awareness subscale, and 0.88 for the entire scale.

Analysis

We adhere to the COREQ checklist (Tong & Craig, 2007) to guide our reporting of the qualitative analysis and results. Steps were taken to improve the rigor, trustworthiness, and validity of qualitative results. First, open-ended responses to the barriers and facilitators questions were coded in Microsoft Excel following a content analysis approach (Hsieh & Shannon, 2005). All coding was completed by the first and senior authors, both of different racial identification and with different levels of experience to increase the trustworthiness and validity of findings. YT is a self-identified Asian female graduate student in counseling and mental health services. NT is a self-identified White male and an early career health equity researcher with experience providing care to racially and ethnically minoritized clients, including in CMH. Coders reviewed all participant responses, met to identify potential codes, and produced a refined codebook with definitions and examples of qualitative themes. After finalizing a codebook, coders independently coded all data again and reached a consensus through group dialogue. This was essential to ensure agreement and validity. Each theme was coded as either present or absent in each clinician’s response. The themes were presented back to 20 community mental health clinicians (including some who did and did not participate in the survey) in a Zoom meeting. This step was taken to member-check and further enhance trustworthiness and validity.

We utilized a convergent mixed-method design (Creswell & Plano Clark, 2007) to explore relations between clinicians’ perceived barriers and facilitators to discussing race and racism and their multicultural knowledge and awareness. We calculated descriptive statistics to describe clinicians’ MCKAS-R scores. Qualitative results were transformed into quantitative counts, wherein each theme was coded as either present or absent in each clinician’s response. We then calculated Spearman’s rank-order correlations between transformed quantitative counts of themes and MCKAS-R mean scores. We conducted an exploratory analysis to examine the potential associations between each reported barrier and facilitator with MCKAS-R mean scores. We ran separate linear regression models for barriers and facilitators, with one model having all barriers regressed onto MCKAS-R scores, and another model having all facilitators regressed onto MCKAS-R scores.

Results

Qualitative Results

We organized themes of clinicians’ perceived barriers and facilitators into four levels: client behavior, clinician behavior, organizational characteristics, and structural characteristics. Table 2 provides detailed definitions of themes.

Table 2.

Qualitative Themes, Definitions, and Frequency

Level	Theme	Definition	n
Client	Barrier: Perceived Client Disinterest	Clients are not interested in discussing issues of race or racism, evidenced by shutting down conversations about race and racism.	19
	Barrier: Anticipated Conflict	Clinicians anticipated conflict in broaching topics of race and racism, which led them to avoid discussions.	7
	Barrier: Age	Clinicians’ perception that clients are too young to have conversations regarding race or racism.	3
	Barrier or Facilitator: Timing	Clinicians’ perceptions that clients are not interested or not ready to discuss race or racism at a given time. Clinicians reported broaching conversations earlier in therapy was easier.	12
	Facilitator: Client-Initiated	Clinicians are willing or open to discussing race or racism when client introduce the topics.	56
Clinician	Barrier: Clinicians’ Passive Engagement	Clinicians are willing or open to discussing race or racism when client initiated but will not initiate the conversation themselves.	22
	Barrier: Clinician Race	Clinicians assume their having a different racial identification than clients will be a barrier to discussing race or racism.	16
	Barrier: Clinician Knowledge	Clinicians’ reported lack of knowledge regarding how to start, effectively maintain, and or stop conversations regarding race or racism.	11
	Barrier: Clinicians’ Perception of Harm	Clinicians’ reported fear of having attempts at discussing race or racism harming or “re-traumatizing” clients.	11
	Barrier or Facilitator: Clinician Self-Efficacy	Clinicians’ self-efficacy and confidence in their ability to discuss race or racism, leading to them avoiding or engaging in conversations.	11
	Barrier or Facilitator: Clinicians’ Perception of Relevance	Clinicians are less likely to broach race or racism when they do not find it relevant to treatment. Conversely, they are more likely to broach the topic when it seems relevant to presenting problems.	24
	Barrier or Facilitator: Clinicians’ Perception of Rapport	Clinicians’ perception that their rapport or therapeutic alliance is too weak to broach conversations regarding race or racism. Conversely, perceptions of strong rapport makes clinicians more likely to broach conversations.	9
	Facilitator: Clinicians’ Willingness and Interest	Clinicians are willing and interested in discussing race or racism with clients.	16
	Facilitator: Shared Racial Narratives	Clinicians report it is easier to engage in conversations regarding race or racism when they can relate on personal level, such as sharing a minoritized racial identification.	14
	Facilitator: Clinician Self-Awareness	Clinicians reported they are more likely to broach conversations regarding race or racism because they are aware of their own beliefs, biases, and attitudes.	11
Organization	Facilitator: Training	Clinicians reported they were more likely to broach conversations after receiving organization-supported training or education.	8
Society	Barrier: Language & Cultural Differences	Language differences made clinicians less likely to discuss issues of race or racism.	2
	Facilitator: Current Events	Clinicians reported referencing current events and news to prompt discussions of race or racism.	21

Client Behavior Level

Barrier: Perceived client disinterest.

One frequent barrier cited at the client behavior level was clinicians’ perception of clients’ disinterest in discussing race and racism. Clinicians explained some clients would say that race and racism were “not something that they want/need to discuss/process” (Clinician 1, White, 39% Clients of Color [CoC] on caseload). Clinicians then justified not exploring race and racism as “following the lead [of the client]” (Clinician 22, White, 63% CoC caseload). They took clients’ “disinterest” as an indication that clients “do not want to include racial [explorations] as part of their therapeutic journey” (Clinician 20, Asian, 100% CoC caseload). Clinicians’ perceptions of their clients’ disinterest in exploring race and racism also contributed to other challenges, such as clinicians’ lack of confidence to probe further with seemingly disinterested clients.

Barrier: Anticipated conflict.

Clinicians anticipated conflict in broaching topics of race and racism, which led them to avoid discussions. The anticipated conflict theme was seemingly more salient when the client and clinician did not share the same race or ethnicity. One clinician described clients not wishing to engage in discussions “unless you see things only [the client’s] way” (Clinician 43, White, 26% CoC caseload). These challenges also extended to working with clients whose families might have had conflicting values, leaving clients with limited opportunities to engage in conversations about race and racism. This was particularly challenging when “working with a youth who does not have these conversations at home, or [whose] family has strong opinions [about related topics]” (Clinician 59, White, 40% CoC caseload).

Barrier: Age.

Several clinicians perceived a client’s age as a barrier to discussing race and racism. Clinicians report they would be less likely to bring up the topic if clients were younger, noting: “I think I am less likely to bring it up due to younger age” (Clinician 20, Asian, 100% CoC caseload). Clinicians also described how younger clients would seemingly shut off discussion, “...they may brush off the topic and didn’t want to discuss race; especially for the younger clients” (Clinician 99, Asian, 80% CoC caseload).

Barrier or Facilitator: Timing.

Clinicians frequently mentioned timing as a barrier to discussing race and racism with their clients. One clinician noted, “If the client comes into the session with another identifying issue (such as trauma), I will stick on that topic… and bring [race and racism] up at a more relevant time” (Clinician 18, White, 0% CoC caseload). Furthermore, clinicians commonly mentioned that they perceived it was too early in treatment and clients were not emotionally prepared to have conversations related to race and racism: “Generally, I don’t bring this up if I’ve just met the client or I suspect that my bringing it up would be perceived as an attempt at rapport-building” (Clinician 47, White, 45% CoC caseload). Some clinicians also stated that they preferred to “focus on symptoms first, then look at root causes” (Clinician 105, White, 10% CoC caseload), describing how they believe topics of race and racism may be relevant to presenting problems but prefer not to address them in the beginning sessions. Conversely, clinicians indicated they are more likely to broach conversations about race and racism if the topic was either brought up during intake or early in treatment. One clinician noted, “… it feels like it opens the door and sets the stage for future conversations” (Clinician 9, White, 43% CoC caseload).

Facilitator: Client-initiated.

Clinicians most frequently noted facilitator was when clients broached topics of race and racism first. Clinicians reported being more likely to discuss race and racism “when [clients] bring the topic up first or bring up a topic that segues into the conversation” (Clinician 10, White, 40% CoC caseload). Clinicians also reported that sometimes clients would directly ask to discuss race and racism: “I was working with a Black client who, at intake, made it known that she wanted to talk about her experience as a Black person as well as the fears she had of racism and discrimination” (Clinician 53, White, 0% CoC caseload). Clinicians also noted that when clients shared how they viewed aspects of their racial and ethnic identity as a strength, it made it easier to broach conversations: “Clients identify aspects of their race/culture that they view as strengths, e.g., tribal networks, faith communities, large extended families that contribute positively to their identities and sense of well-being” (Clinician 49, White, 45% CoC caseload).

Clinician Level

Barrier: Clinicians’ passive engagement.

Clinicians commonly described how they were willing to engage in discussions but would not initiate the topic themselves unless the clients brought it up first. One clinician described, “If the client didn’t bring it up, I will check in about things, but if the client doesn’t engage or pushes it away, I won’t press” (Clinician 62, race not reported, 44% CoC caseload). Related to this theme was clinicians’ endorsement that they would only broach topics of race and racism if they felt it was part of the client’s therapeutic goals, “...if a client brings it up as a therapeutic goal, then racism would be discussed” (Clinician 78, White, 80% CoC caseload). Clinicians’ passive engagement with discussions of race and racism was often related to feelings that they were not knowledgeable on the topic, perceptions of weak rapport with clients, or clinician self-efficacy in discussing race and racism. As one clinician explained: “I have considered that this may be because I am a White female, and that made them less comfortable or think I may not understand. I have thought about whether or not I am presenting in a way that shows that I am open to being an ally and helping them to address the impact of race with me” (Clinician 53, White, 0% CoC caseload).

Barrier: Clinician race.

Clinicians acknowledged how having a different racial identification than the racial or ethnic group in which they identified their clients led to them feeling hesitant and less comfortable addressing race and racism. As one clinician described, “Also, I’m White, and that feels weird for a White person with more power in the relationship to talk about race” (Clinician 61, White, 21% CoC caseload). Some clinicians also noted how they did not want to inadvertently reinforce racist power dynamics by having the discussion: “..[I] do not want to be perceived as speaking over voices of color” (Clinician 102, White, 60% CoC caseload); “I am not sure whether I was seen as an ally, or a representative of the dominant, oppressive culture” (Clinician 49, White, 45% CoC caseload).

Barrier: Clinician knowledge.

Clinicians frequently reported lacking knowledge regarding how to start, maintain, and/or stop conversations about race and racism. Clinicians indicated they were uncertain and worried their lack of knowledge might result in them being unhelpful or placing additional burdens on their clients: “If I didn’t know enough, I didn’t have to want the client to be in a position to educate me” (Clinician 58, Multiracial: Asian & White, 80% CoC caseload). In addition, clinicians referenced concerns that their lack of knowledge and skills would harm clients should they engage in conversations about race and racism: “In the past, there have been times because I didn’t have the skills to navigate those conversations or because I was worried about committing microaggressions or saying something ignorant as a White therapist” (Clinician 114, White, 15% CoC caseload).

Barrier: Clinicians’ perception of harm.

Related to many themes above, clinicians fear that conversations about race and racism would be harmful or retraumatizing as another barrier to having discussions about race and racism. One clinician noted their “anxiety that [they] would perpetuate harm/tokenism” (Clinician 110) led them to avoid discussions. Clinicians also expressed not broaching topics of race and racism because they were “being sensitive to the risk of re-traumatization” (Clinician 56, White, 32% CoC caseload). Although clinicians may perceive addressing race and racism as a good practice, they may be hesitant and fear that “asking [about race/ racism] may present as a trigger or worsen the situation” (Clinician 12, Multiracial: Asian & White, 0% CoC caseload). Finally, clinicians also noted how politics influenced these cognitions and led them to avoid conversations “when it is politically heated and discussing race may lead to unintended consequences” (Clinician 97, White, 50% CoC caseload).

Barrier or Facilitator: Clinician self-efficacy.

Clinicians self-efficacy or confidence in their ability to broach conversations about race or racism acted as both a barrier and facilitator. Clinicians often mentioned not feeling confident in their ability to discuss race and racism or hesitating to broach the topics because of feeling uncomfortable with how conversations might proceed. Several other themes were related to clinicians’ self-efficacy, including their race, knowledge level, fear of making clients uncomfortable, and uncertainty about their client’s comfort level with these discussions. Clinicians were hesitant to bring up topics because of “Feeling ill-prepared” (Clinician 77, White, 30% CoC caseload) or being uncertain of how to “open that topic gracefully or genuinely” (Clinician 33, White, 20% CoC caseload). Additional barriers that were related to the clinician’s self-efficacy involved clinicians’ perceptions that clients were disinterested in discussing race and racism: “At times the conversation gets shut down, which makes me less confident [to discuss race and racism]” (Clinician 13, Hispanic, 60% CoC caseload). Clinician values or politics also interacted with self-efficacy: “When the race was combined with political undertones, I felt particularly uncomfortable” (Clinician 50, White, 2% CoC caseload).

Conversely, clinicians often mentioned having greater self-efficacy because of their lived experience or professional experience working with Clients of Color. One clinician described, “I have worked with the Latino population for over ten years and through experience have seen challenges faced by the community” (Clinician 23, Multiracial: Asian & White, 80% CoC caseload). Clinicians also reported confidence in broaching conversations about race and racism as a result of their own education and advocacy efforts: “I felt comfortable because I keep myself aware of social issues and try to educate myself and be aware of my privilege as a White person in America” (Clinician 103, White, 50% CoC caseload).

Barrier or Facilitator: Clinicians’ perception of relevance.

Clinicians reported not broaching race and racism to focus on the client’s experience, “I don’t bring it up, I meet clients where they’re at, and sometimes race isn’t part of that experience” (Clinician 31, White, 10% CoC caseload). Clinicians also expressed beliefs that racism may not always be part of clients’ experience: “I don’t think it is fair to expect each person of color to have experienced racism” (Clinician 28, White, 20% CoC caseload). Clinicians mentioned their openness to discussing race and racism if they deemed it relevant. As one clinician explained, “I find that with my clients of color, their race and cultural background is typically already part of the discussion, as they already have familiarity of how their race impacts other issues that they come to counseling for” (Clinician 6, Multiracial: Asian & White, 30% CoC caseload).

Barrier or Facilitator: Clinicians’ perception of rapport.

Clinicians frequently reported they would not initiate the topic before establishing a solid rapport with clients: “If I don’t have a strong enough rapport with clients, then I don’t broach the topic unless they do” (Clinician 67, Asian, 50% CoC caseload). Other clinician characteristics often influenced these perceptions, such as being a more novice clinician: “Being earlier on in my therapeutic experience and fearing I would say something to damage therapeutic alliance or make the client uncomfortable” (Clinician 117, White, 30% CoC caseload). Conversely, perceptions of stronger rapport led clinicians to be more likely to broach conversations.

Facilitator: Clinicians’ willingness and interest.

Clinicians’ willingness and interest in discussing race and racism was a frequently cited facilitator. This was associated with an understanding that clients’ perspectives on their race and any experiences with racism were critical to better understanding and assisting clients in their treatment process. As one clinician described, “I take a broad view of multicultural awareness and sensitivity. Race is a critical component of that view. I strive to know what motivates and will also help positive change remain ” (Clinician 22, White, 63% CoC caseload). Clinicians also validated the positive effect of discussing race and racism with clients as opportunities to learn about clients and build rapport while drawing from their other skills, such as safety planning, to support clients surrounding experiences of racism.

“I had a client who told me that after the election results, he was fearful of leaving his house because he was worried about being targeted by White supremacists (which was reported that White supremacist groups were more active that week) I was able to validate his experience and discuss with him about the fears of being a young Black man in America.” (Clinician 103, White, 50% CoC caseload).

Facilitator: Shared racial narratives.

Clinicians reported it was easier to engage in conversations about race and racism because of their own lived experience (most frequently as someone with a racially and/or ethnically minoritized identity). One Clinician of Color explained the comfort with which they broach the topics, “I’m a person of color and recognize our experiences affect our mental health. This leads me to be very comfortable in bringing up examples of how awareness of race can be helpful.” (Clinician 100, Multiracial: Black and White, 60% CoC caseload). Clinicians also mentioned how their shared racial backgrounds made it easy to relate and empathize with clients in these discussions: “Being that I am Black and Latina and have experienced racism…” (Clinician 104, Black and Latina, 3% CoC caseload). Some clinicians also referenced how their other identities, such as being parents to bi-racial children, influenced their experience having conversations about race and racism: “Since I work with kids and am the parent of bi-racial children, sometimes I will mention that my own kids look like them and I have pictures of my children in my office, to help them feel more comfortable talking about these issues with me (since I am White)” (Clinician 109, White, 25% CoC caseload).

Facilitator: Clinician self-awareness.

Clinician’s awareness of their own beliefs, biases, and attitudes was also a commonly cited facilitator in having discussions about race and racism. Clinicians reported feeling obliged to educate themselves to broach the topics with humility. One clinician explained, “As a White, cis-gendered female clinician, I believe it’s my responsibility to acknowledge my privilege and enter into conversations about race and/or racism with humility” (Clinician 42, White, 99% CoC caseload). Clinicians of Color referenced their lived experiences and have heightened awareness that discussing racial identification and racism facilitated the treatment process.

Organizational Level

Facilitator: Training.

Clinicians noted how additional training on cultural humility or other topics related to treating Clients of Color helped them to have conversations regarding race and racism. One clinician explained, “Upon partaking in… professional consultation with trained staff at my work… [we were] strongly encouraged to address racial issues in therapy sessions” (Clinician 74, White, 15% CoC caseload). Clinicians’ references to training and education were also linked to other themes, including self-awareness. One clinician explained, “Continuing education about how to do this as a White therapist without perpetuating White supremacy/fragility” (Clinician 110, White, 32% CoC caseload).

Societal Level

Barrier: Language & cultural differences.

Language barriers were noted as a societal barrier in having conversations about race and racism. Clinicians reported difficulty communicating and conveying needs when: “the interpreter can’t always translate what I need” (Clinician 119, Black, 20% CoC caseload). Cultural differences between the U.S. and other countries were also cited as a barrier. One clinician explained: “It is really hard to discuss what it means to be a person of color when working with undocumented youth that have never heard this term before. It is like teaching them a whole new world of what it means to be a person of color and what the words translate to” (Clinician 108, self-reported “other” race, 31% CoC caseload).

Facilitator: Current events.

Clinicians commonly mentioned referencing current events or the news to initiate conversations about race and racism. Clinicians indicated media coverage of incidents of racism provided an avenue to bring up race and racism with their clients. One clinician commented, “When there are prominent events in the news or culture that involve PoC [Person of Color], it is much easier to approach the topic as it may have a direct impact on the client through exposure to the information” (Clinician 36, Multiracial: Black and White, 56% CoC caseload). Many clinicians mentioned George Floyd’s murder and anti-Asian hate crimes specifically. One clinician shared an instance when the client presented to their session affected by George Floyd’s murder, “Client presents to a session upset regarding George Floyd’s death. Speaks deeply about his own feelings of “separateness” from most people because of his skin color ” (Clinician 47, White, 45% CoC caseload).

No Perceived Barriers

One notable finding is that when asked about the times clinicians chose not to address race with their clients, four clinicians reported constantly engaging in discussions and not perceiving any thoughts or feelings that influenced their ability to engage in these discussions. However, these comments do not specify why they may engage in these discussions or what made it easier to broach the topics. One clinician indicated, “When clients bring up race or initiate conversations, I always engage” (Clinician 16, White, 18% CoC caseload). One clinician explained, “If the topic is brought up, I am comfortable maintaining the conversation with Motivational Interviewing tactics” (Clinician 66, White, 7% CoC caseload).

Quantitative Results

The means, standard deviations, and intercorrelations among the variables are presented in Table 1. The MCKAS-R means (Knowledge M= 5.16, SD 0.84; Awareness M = 6.07, SD = 0.71; Overall M = 5.51, SD = 0.66) indicated that the sample on average reported moderate levels of knowledge and awareness in Multicultural Counseling Competence.

Table 1.

Participant Demographics & Descriptives

Variable	n	%
Race
White	85	73.9
Black or African American	7	6.1
Asian	5	4.3
American Indian or Alaska Native	2	1.7
Multiracial	12	10.4
Other	4	3.5
Age
18 – 24	1	0.9
25 – 34	51	44.3
35 – 44	36	31.3
45 – 54	15	13.0
55+	12	10.4
Gender
Female	89	77.4
Male	17	14.8
Non-binary / transgender	4	3.5
Other (Self-Described)	3	2.6
Prefer Not to Say	2	1.7
Ethnicity
Hispanic or Latino/a/x	9	7.8
Degree
Degree from 2-year college	1	0.8
Degree from 4-year college (e.g., BA, BS)	10	8.5
Master’s degree	101	85.6
Doctoral degree	5	4.2
Other	1	0.8
Caseload Demographics	M	SD
% Clients of Color	36.3	25.7
% Children/Adolescent	71.1	34.4
Multicultural Counseling Knowledge and Awareness Scale (MCKAS)	5.51	0.66
Knowledge Subscale	5.16	0.84
Awareness Subscale	6.07	0.71

A Spearman’s rank-order correlation was run to assess the relationship between each clinician’s total count of perceived barriers and facilitators in addressing race with clients of color and their MCKAS-R mean score. 5 participants’ answers were excluded due to lack of qualitative data (i.e., they did not respond to open-ended questions). Preliminary analysis showed the relationship to be monotonic. There was no statistically significant correlation between the number of coded barriers and MCKAS-R scores, r_s(112) = −0.089, p=0.346, 95% CI [−0.15, 0.08]. There was also no statistically significant correlation between the number of coded facilitators and MCKAS-R scores, r_s(112) = 0.022, p = 0.815, 95% CI [−0.07, 0.21].

We conducted an exploratory analysis to examine the potential associations between each reported barrier and facilitator with MCKAS-R mean scores. Clinician reported irrelevance of race and racism (i.e., clinicians avoid discussions when they deem race or racism to be irrelevant) was associated with lower MCKAS-R scores, ß = −0.73, t(108) = −3.49, p = 0.001, 95% CI [−1.21, −0.31]. No other factors reached statistical significance (all p>0.05).

Discussion

The present study examined clinicians’ perceived barriers and facilitators in broaching race and racism with clients holding minoritized racial and ethnic identities. The themes that emerged most frequently as barriers to addressing race and racism included clinicians not engaging unless clients initiated, clinicians avoiding discussions of race and racism because of feeling uncomfortable or unconfident, and clinicians’ assumptions that their racial identifications would be a barrier to discussions. Most frequent facilitators to addressing race and racism included the client’s initiation, emotional openness, and availability to have discussions about race and racism; current events that provided an avenue to prompt discussion; and the clinician’s willingness and intentions to address racism through asking or actively listening. Clinicians’ endorsement of barriers and facilitators of discussing race and racism were not associated with quantitative measures of multicultural counseling knowledge and awareness.

While the quantitative measures indicated that clinicians felt reasonably competent in multicultural counseling and awareness, our qualitative analysis reveals a potential contrast, highlighting a misalignment between their self-perceived competence and their actual practices. Despite frequently asserting their readiness to discuss race and racism when determined as clinically relevant, qualitative data also suggests clinicians often hesitated to initiate these conversations, preferring instead to wait for clients to bring up the topics themselves. This discrepancy between their cognitive insight—believing they are comfortable and confident in addressing these issues—and their actual behavior—waiting for clients to take the lead—underscores a critical gap. Clinicians who commonly avoided discussions of race and racism, or may have only passively engaged, effectively placed the onus on the client to mention their race or experiences of racism. The tendency for clinicians to engage only passively was related to other perceived barriers, such as inappropriate timing, lack of confidence to engage in these conversations thoughtfully and respectfully, and perceived lack of knowledge. Research shows that clinicians may struggle to find what they deem is the appropriate time to address issues of race and racism in counseling (Brown et al., 2013). Our present findings also suggest that mentioning race and racism early on, such as in initial intake sessions, may aid clinicians in feeling like they have set the expectation that race and racism are topics to be discussed and explored in therapy.

Misperceptions that clinicians would “re-traumatize” clients by broaching topics of race and racism were frequently mentioned and related to clinicians’ hesitancy to engage in these conversations. Though these concerns are rooted in a desire to be supportive, the avoidance of discussions of race and racism may invalidate clients’ experiences and ignore the existence of White racial privilege and supremacy (Bernal, 2003). Clinicians’ passive engagement and decisions to let clients initiate conversation may perpetuate power dynamics and White racial privilege by further burdening clients. Clinicians’ avoidance of topics of race and racism may leave their clients unsure about their clinician’s awareness or openness to discussing race and racism, consequently impeding the development of therapeutic alliance and treatment outcomes (Brown et al., 2013). Neglecting to consider a student’s cultural background can lead to overlooking important information or misinterpreting the underlying causes and progression of their challenges (Jones et al., 2020). Our study results have important implications for identifying behavioral goals for training clinicians to adopt an anti-racism framework by actively addressing perceived barriers and facilitators (some rooted in misconceptions) to improve cultural humility and ensure Clients of Color receive high-quality, holistic, and culturally responsive care.

Interestingly, the number of barriers and facilitators mentioned by each participant was not related to our quantitative measure of multicultural counseling and awareness—the MCKAS-R. This may reflect our methodology. Our qualitative and quantitative measures assessed complementary yet distinct constructs (i.e., though perceived barriers and facilitators were related to knowledge and awareness, our qualitative questions were phrased much more broadly). Importantly, though, quantitative measures suggested moderate levels of multicultural counseling knowledge and awareness on average. We believe that complementing these measures with qualitative data adds nuance. For example, though lack of knowledge and awareness were barriers to discussing race and racism, qualitative data also highlights the importance of attending to clinicians’ confidence or self-efficacy in addressing the issues when equipped with competent tools.

The nuances between our quantitative and qualitative results parallel current thinking about multicultural competence and cultural humility. Current thinking suggests that humility complements cultural competence (Zhu et al., 2022). The synergetic integration of cultural competence and humility enables clinicians to demonstrate a behavioral alignment in cultural attunement, fostering an effective multicultural counseling environment (Mosher et al., 2017; Rovitto, 2022; Zhu et al., 2022). Understanding this is an avenue for future research, including further investigating interactions between competence and humility, and how competent behaviors or skills might align (or diverge) with how competence is conceptualized and measured.

Limitations

Our results should be considered within the context of their limitations. One limitation of the current study is the demographic composition of predominantly White clinicians. It is important to note that the majority of the mental health workforce is White, non-Hispanic, or Latina. While efforts to diversify the workforce are critical, so too are efforts to improve the capacity of the current workforce to work with clients of all backgrounds. Another limitation is our qualitative approach, which provided nuanced data on clinician behavior that does not directly relate to knowledge and awareness as measured by the MCKAS-R Scale. Further, this study is limited by self-report and recall biases.

Conclusion

It is essential to attend to all elements that may influence clinicians’ work with racially and ethnically minoritized clients. Targeting clinicians’ multicultural competency and cultural humility jointly may help clinicians assess their strengths and weaknesses in counseling culturally diverse clients. We emphasize that clinicians’ playing an active, but not coercive, role in opening the door for discussions of race and racism is an essential step toward practicing cultural humility.