Windows of Cultural Opportunity: A Thematic Analysis of How Cultural Conversations Occur in Psychotherapy

Abstract

A cultural opportunity is one of three pillars within Multicultural Orientation Framework; it is defined as a moment in therapy when aspects of a client’s background emerge, and which can be deeply explored to better understand salient aspects of a client’s cultural identities. Research on cultural opportunities provides evidence that clients desire cultural conversations. However, no study to date has examined what cultural opportunities sound like in therapy and how therapists and clients utilize these opportunities. Accordingly, the purpose of this study was to examine the ways in which cultural conversations emerge during first psychotherapy sessions and how clients and therapists engage in these cultural conversations. Psychotherapy sessions from diverse therapist-client pairings at a university counseling center (n = 22) were analyzed using (reflexive) thematic analysis. Qualitative findings revealed four themes around how cultural opportunities emerge (e.g., windowpane of feeling) and three themes in how they are responded to (e.g., look out the same window: using client’s language to explore culture). Implications for therapist training and supervision are discussed.

The conversations between therapist and client in psychotherapy are, in essence, cultural conversations: verbal and non-verbal exchanges which communicate values, worldviews, and cultural beliefs (Day-Vines, 2007; Hays, 2008). These cultural conversations are often focused on helping clients gain more insight into how their social and cultural identities influence their everyday lived experiences and are perhaps linked to their presenting concerns. Therapists are thus tasked with an incredibly important role to ensure that these cultural conversations take place and to treat psychotherapy as a window of opportunity for clients to change and heal (Owen et al., 2016; Tsang et al., 2011). The literature maps varying avenues to explore cultural conversations in psychotherapy, such as through examination of theoretically driven interventions (e.g., self-disclosure; feminist-multicultural theory; Brown, 1990), cross-cultural conversations (see Asnaani & Hofmann, 2012), and relational ruptures (e.g., microaggressions; Cheng et al., 2018; Owen et al., 2018, Shelton & Delgado-Romero, 2011). Research suggests that cultural conversations are desired by clients who hold marginalized identities (Meyer & Zane, 2013). Yet how therapists engage with historically marginalized clients vary quite significantly (Imel et al., 2011); this level of engagement may account for approximately 5% of the variance in missed opportunities for exploration of salient aspects of a client’s identity (Owen et al., 2016). Accordingly, we sought to conduct a study that provides actual examples of how cultural conversations surface in initial psychotherapy sessions and ways in which therapy dyads engage in these cultural opportunities.

Research on multicultural competencies (MCC; i.e., cultural awareness, knowledge, skills; Sue et al., 1992) has offered guidance into how psychologists may prepare for working with culturally diverse and minoritized clients. A culturally skilled counselor may, for example, provide therapeutic interventions that take into account a client’s cultural background (Arredondo et al., 1996). Studies on MCC also point to the salience of applying multicultural competencies for all clients, including those who may hold socially privileged identities (e.g., white clients; Tao et al., 2015), pointing to the complexities of identity (see Hays, 1996; Hays, 2008). More recently, we see cultural conversations being explored in an emerging framework, called Multicultural Orientation (MCO).

Multicultural Orientation (MCO) Framework

The concept of MCO provides a framework for therapists that acknowledges the varying cultural factors both clients and therapists bring into therapy (Davis et al., 2018; Owen et al., 2011). More specifically, MCO highlights the process in which therapists’ and clients’ identities enter, converge, and interact with one another throughout therapy, and how this interplay of identities supports the client in their therapeutic healing (Davis et al., 2018). Characterized as a way of being with a client, MCO is enacted through three pillars. The first pillar, cultural humility, is defined as an other-oriented stance, situating the client as the expert on their own experiences, and approaching cultural identities with curiosity and openness (Hook et al., 2013). Secondly, cultural comfort is the level of one’s ability to engage in conversations around another person’s cultural identities (Davis et al., 2018). This involves therapists’ self-awareness of their own emotional, physiological, and behavioral cues, which influence their ability to stay present with their clients. The third pillar, cultural opportunities, the focus of this study, is defined as openings to meaningful exploration of salient aspects of the client’s identity, including social identities that are not historically marginalized (Owen et al., 2016). Researchers posit these opportunities for deeper cultural conversations arise quite frequently, as both the client and therapist contribute aspects of their cultural values, implicitly and explicitly, to every counseling session (Davis et al., 2018).

While the MCO framework is a relatively new area of study, the current literature offers promising connections between the three pillars and treatment outcomes. Cultural humility, for example, has been shown to be related to higher self-reported treatment outcomes by clients in a group setting (Kivlighan et al., 2018). Similarly, clients’ perceptions of their therapist’s cultural comfort, specifically around race/ethnicity, has been linked with the number of unilateral terminations by clients of color (Owen et al., 2017), as well as working alliance and treatment outcomes (Perez-Rojas et al., 2019a). Additionally, research suggests that the number of cultural opportunities that are explored in therapy is associated with improved treatment outcomes (Owen et al., 2016). Investigations of cultural opportunities are further highlighted in the sections, below.

Cultural Opportunities

The literature investigating cultural opportunities is expanding, shining light on how cultural conversations are (or are not) taking place in individual therapy (Anders et al., 2020; Drinane et al., 2018; Owen et al., 2016), group therapy (Kivlighan et al., 2018; Kivlighan & Chapman, 2018), and clinical supervision (Hook et al., 2016; King et al., 2020; Zhao & Stone-Sabali, 2020). Researchers have proclaimed the attunement to cultural opportunities in individual therapy as important for clients and can be particularly helpful when considering cultural factors for specific groups (Adams & Kivlighan, 2019; Gafford et al., 2019). For example, a study with incarcerated clients demonstrated the importance of religious beliefs as a source of strength and hope (Gafford et al., 2019), while another study highlighted trauma and forced relocation as important areas to broach when working with refugee populations (Adams & Kivlighan, 2019). Thus, our current understanding of cultural opportunities is organized into two areas: (a) the therapist’s ability to detect and attune to cultural opportunities and (b) suggestions for how to leverage cultural opportunities in practice. We provide a brief overview of these two areas, below.

Detecting & Attuning to Cultural Opportunities

The ability to recognize when a cultural opportunity is occurring has often been investigated by asking the inverse: how often are cultural opportunities missed by therapists? For example, to aid their investigation of the relationship between client’s ratings of their therapists’ cultural humility and perceived missed cultural opportunities, researchers utilized the Cultural Missed Opportunity scale (CMO; Owen et al., 2016). The CMO is a 5-item measure, which asks clients to indicate the extent to which they agree or disagree with a set of statements (e.g., “My therapist missed opportunities to discuss my cultural background” (Owen et al., 2016, p. 33). Findings indicate clients who reported less cultural conversations with their therapist also reported worse therapy outcomes (Owen et al., 2016). It was also found that cultural humility was an important factor when examining the impact of missed cultural opportunities on treatment outcomes. Specifically, the more humble a therapist was perceived to be, the less of an impact missing cultural opportunities had on treatment outcomes. These findings suggest that cultural humility may act as a buffer to missed cultural opportunities in session (Owen et al., 2016).

A recent study investigated the relationship between how salient clients rate their identities to be, and their perception of their therapists’ cultural humility and missed cultural opportunities (Anders et al., 2020). Findings revealed that clients who reported only one identity as high in saliency perceived their therapists as more culturally humble and willing to explore cultural aspects of their identity. However, clients who identified two or more identities as high in saliency reported their therapists as less culturally humble and having missed more cultural opportunities. Researchers pose that clients with more complex identity constellations may require a richer exploration of identities they hold (Anders et al., 2020). Thus, an exploration of how cultural conversations are occurring and being engaged with during real counseling sessions may provide insight as to how we can tailor interventions to better explore the numerous identities our clients hold.

Leveraging Cultural Opportunities in Practice

The literature offers guidance in how to address and engage in cultural opportunities that occur in session through provision of case examples and client/therapist reports of the nature of cultural conversations that they had at a previous time point. For instance, a recent case study investigated how cultural processes are experienced in a cross-cultural counseling dyad using the MCO framework (Gundel et al., 2020). Interviews with a client and her therapist highlighted the therapist’s openness and attunement toward cultural conversations, and a willingness to integrate the client’s salient identities into the counseling process. Both therapist and client also expressed an expectation for cultural factors to be discussed in treatment, explaining that the therapeutic progress they made would not have been possible without the integration of cultural components (Gundel et al., 2020). Findings from this study suggest that incorporation of cultural factors into treatment is not only important but may also be an expectation that clients hold for their therapist.

The current MCO literature has offered hypothetical scenarios in varying areas of treatment that MCO components, such as cultural opportunities, can be integrated into (Davis et al., 2018). During the intake, for example, therapists may initiate cultural conversations by explicitly stating that cultural identities and experiences are important to the therapeutic process. Researchers also assert that explicit conversations around potential cultural ruptures (i.e., microaggressions), how they may manifest in therapy, and methods the dyad can take to address them are also important discussions to have during intake (Davis et al., 2018). By initiating conversations around the importance of identity and cultural ruptures, particularly during the first meeting with the client, the therapist is offering windows of opportunity to delve into salient aspects of who the client is. Given the potentiality of cultural conversations occurring during the first meeting with the client, examination of how dyads are engaging in cultural conversations during the first therapy session is needed.

The existing MCO literature underscores the importance of learning how to welcome, attune to, and broach cultural conversations in psychotherapy, however there are still areas to further understand. First, to the best of our knowledge, there are currently no examples of how cultural opportunities arise in session with real clients. Second, despite evidence that supports leveraging cultural conversations in early psychotherapy sessions (Boyd-Franklin, 2003; Fuertes et al., 2002; Thompson Sanders, 1994), no study to date has examined if and how cultural opportunities present in the first session.

Current Study

The current study aims to provide readers with a view of how cultural opportunities present and are engaged with in session. Several key pieces of the literature helped to shape our approach. First, while the subjective experiences of therapists and clients are important areas to explore, we were interested to learn how windows of opportunity actually arose in session. Prior studies have utilized methods, such as self-report, to investigate cultural opportunities (Anders et al., 2020; King & Borders, 2019; Owen et al., 2016) however, evidence suggests that therapists may not always be aware of when cultural opportunities occur in session (Owen et al., 2016). Moreover, cultural opportunities have been defined as markers, or indicators of cultural content in session (Owen et al., 2016). Accordingly, we were interested in identifying cultural markers that occur within psychotherapy sessions (e.g., “I don’t like explaining my sexual orientation to people, that’s why I just tell them I’m gay;” “I learned that, as women, we are taught to apologize for everything”) and examining how these cultural opportunities were addressed. Our central research questions were: (a) How do cultural opportunities emerge in the first psychotherapy session? and (b) How do therapists and clients engage in cultural conversations?

Method

Participants

Participants included 22 pairs of clients and their therapists at a university counseling center (UCC) of a large public research university, located in a predominately white Mountain West State. The sample includes racially diverse clients who have attended at least two sessions (first session is the intake) and are varied based on client self-report of gender identity and religious affiliation. Therapist-client pairings also vary based on racial-ethnic identity to ensure a more diverse representation of counseling dyads (n=22; see Table 1 for demographics). Pseudonyms were used to protect the anonymity of participants.

Table 1.

Demographics

Therapist characteristics		Client characteristics
Pseudonym	Race-ethnicity	Pseudonym	Race-ethnicity	Gender identity	Religious affiliation	Presenting concerns
Lee	REM	Kevin	REM	Man	Other	Loneliness, romantic/relational issues, discrimination
Radko	REM	Ollie	REM	Man	Noneb	Anxiety, romantic/relational issues, academic concerns, early relational trauma
Tosia	REM	Agnessa	REM	Woman	Noneb	Stress, familial issues, romantic/relational issues
Taavi	REM	Grey	REM	Non-Binary	Christiana	Early relational trauma
Han	REM	Aguilar	REM	Non-Binary	Noneb	Familial issues, financial stress, lack of familial support around gender identity
Gerold	REM	Dillon	White	Man	Christiana	Depression, anxiety, romantic/relational issues, transitioning from faith
Paulie	REM	Jakob	White	Man	Noneb	Low self-worth, depression
Lazaro	REM	Cheryl	White	Woman	Christiana	Anxiety, stress, familial expectations
Angelita	REM	Linda	White	Woman	Christiana	Depression, academic demands conflicting with spending time with baby
Leocadia	REM	Brenda	White	Woman	Other	Depression, anxiety, disordered eating
Finn	REM	Madilyn	White	Woman	Noneb	Depression, anxiety, academic concerns, romantic/relational issues
Nour	REM	Peyton	White	Non-Binary	Noneb	Anger, relational issues, gender-minority related fatigue
Suad	White	Morgan	White	Man	Christiana	Anxiety, panic attacks
Carwyn	White	Josh	White	Man	Noneb	Loneliness, anxiety, difficulty adjusting to university
Islay	White	Sieger	White	Man	Noneb	Familial issues, romantic/relational issues
Siana	White	Tallulah	White	Woman	Noneb	Romantic/relational issues, anxiety
Marvin	White	Vicki	White	Woman	Noneb	Grief, relational trauma, panic attacks, suicidality
Dejan	White	Moreno	REM	Man	Christiana	Divorce, depression, difficulty sleeping
Hattie	White	Amrish	REM	Man	Other	Depression, attentional difficulties, familial issues, romantic/relational issues
Jane	White	Peter	REM	Man	Noneb	Early relational trauma, loneliness, relational issues, difficulty adjusting to university
Geffrey	White	Sam	REM	Woman	Christiana	Academic concerns, anxiety, attentional difficulties
Marcus	White	Paola	REM	Woman	Noneb	Depression, suicidality, familial issues, romantic/relational issues

Note. REM = racial-ethnic minority.

^aIncludes Latter Day Saints (LDS), Catholicism, Protestant, and Orthodox.

^bIncludes Atheist, Agnostic, NA, and Prefer not to answer.

Paradigms Guiding the Research

For this study, we utilized an interpretivist paradigm (Yanow & Schwartz-Shea, 2014) to guide our analysis. Through this perspective, we recognize the complexity of the psychotherapy phenomenon, that there are many interpretations and no objective reality. Thus, in the section on researcher positionality, we name our own researcher subjectivities, who enter in with biases and assumptions; the analyses of transcripts were invariably influenced by our own worldview and assumptions.

We also drew from feminist and multicultural theories, which normalize the variability of the human experience and view contextual differences as informative to the client’s behaviors, values, and needs (Barrett et al., 2005). By taking an approach informed by power differentials that exist between and within social groups, researchers can better interpret data that reflects the realities of oppressed people (Brown, 1990). As such, the present study took into consideration how individuals’ social identities and positionality related to power and privilege influence their lived experiences. For the purposes of this study, we focus on cultural conversations centered on the spectrum of privileged and oppressed identities and how those may differ across clients of varying identities (e.g., people of color; non-binary gender, queer sexual orientation, minority religious affiliation).

Sources of Data

Data used for the current study is from a larger ongoing national study, Digital Exploration of Psychotherapy (DEPTH), funded by the National Institute of Alcohol Abuse and Alcoholism (NIAAA) and reviewed and approved by the University of Utah Institutional Review Board. Of the ongoing collection of audio-recorded sessions, approximately 100 sessions have been hand-transcribed and analyzed to assess therapeutic topics by the DEPTH coding team. All participants provided consent to have their therapy sessions audio recorded and analyzed prior to study activities.

Demographic data available were limited to therapists’ self-identified race-ethnicity; and clients’ self-identified race-ethnicity, gender, and religious affiliation. Researchers ensured variability of demographic representation across dyads by selecting therapist-client pairings who represented one of four dyads: white-therapist white-client, white-therapist REM-client, REM-therapist white-client, and REM-therapist REM-client. Variability of client gender identity and religious affiliation was also taken into consideration within each dyad group.

Of the 100 prepared transcriptions available, 22 transcripts were eligible for this study. In order for transcripts to be eligible, they must have been (a) the first psychotherapy session and (b) had an audio file in addition to the prepared transcript. The first author listened to all 22 sessions and edited transcripts to ensure accuracy, as well as notate any missing paralinguistic aspects of each conversation (e.g., tone, speed, laughter, crying). Although data were analyzed in a prior study, authors of this study were not part of the DEPTH coding team. Further, the team’s code book and subsequent results were not reviewed to avoid being influenced, and to ultimately maintain the integrity of the present study.

Data Analysis

Thematic analysis (TA) was employed in effort to best identify patterns across cultural conversations that occurred between client and therapist. In line with Kidder and Fine’s (1987) distinction between the “little q” and the “Big Q,” we move away from the post-positivist, quantitative paradigm towards the “Big Q” by situating this work within a qualitative paradigm. Many researchers promote use of TA, describing it as an approach used to identify patterns of meaning across data in the form of themes (Braun & Clarke, 2006; Nowell et al., 2017). Since TA encapsulates a variety of methods (Braun & Clarke, 2006; Braun & Clarke, 2019), we specify our approach as (reflexive) TA (Braun & Clarke, 2019). (Reflexive) TA offers a flexible approach that allows for researchers to select from a variety of paradigms and empirically driven theories to inform their research in a way that demonstrates scientific rigor and trustworthiness (Braun & Clarke, 2019). In addition, (reflexive) TA leans into the subjectivity of the researcher; situating the researcher as both a resource and an instrument in data analysis (Braun & Clarke, 2019; Braun & Clarke, 2020). Therefore, one must engage with the data, theoretical underpinnings, and analysis in a reflexive manner (Braun & Clarke, 2020). Methods that were used to ensure reflexive engagement are further highlighted below.

Researcher Positionality and Trustworthiness

The nature of qualitative research, namely (reflexive) TA, highlights the need for researchers to engage in reflexive practices to understand how researchers’ biases, positionality, and reasons for conducting the current study are impacting data analysis (Braun & Clarke, 2006; Braun & Clarke, 2019; Morrow & Smith, 2000). While the coding process was performed primarily by the first author; consultation regarding coding, theme identification, and writing was done between the first and second author. Thus, positionality was reflected both individually and collaboratively during the consultative process of analysis and writing. Individually, the first author maintained a journal to record reflections and reactions to the data, illuminating patterns of identifying with clients who also held intersecting marginalized identities and a sense of not belonging to the same academic institution (e.g., Impostor Phenomenon; Clance & Imes, 1978). The first and second author also regularly met to discuss how positionality not only presented in the research but also in the first author’s life, classes, lab, and within the advisory relationship. Through regular reflection individually and collaboratively, authors were able to discern how lived experiences, identities, and biases may be impacting how the data was being viewed.

Due to the power of subjectivity in qualitative research (Morrow & Smith, 2000), we briefly discuss the positionalities of the authors to further highlight how our subjective experiences influenced the research process. The first author is a 2nd generation multiracial American, spiritual, invisibly disabled, heterosexual, cis-woman and first-generation high school and college student. At the time of this study, she is a doctoral student who provides psychotherapy to undergraduate students at a practicum site, located at the institution where the current study takes place. The second author is a 2nd generation Chinese American cisgender and heterosexual woman who is middle class, not religious, and able bodied. She is a faculty member and licensed psychologist who provides clinical supervision to master’s and doctoral students. She identifies as a community-engaged researcher and conducts studies related to cultural processes in psychotherapy. She is also doctoral advisor of the first author, which presented an implicit and explicit need to attend to power differences, including which themes were generated and directions our analysis took. The third author identifies as an American middle-class, educated, White, straight, cis-man, who is Atheist, and able bodied. He is a licensed psychologist and currently engages in psychotherapy with adults. He is a member of the DEPTH study research team and site coordinator; thus, was not involved in the analysis process.

We followed a set of procedural steps that were not necessarily linear but rather iterative and recursive; allowing for steps of the sequential process to be revisited time and time again without restriction (Braun & Clarke, 2006; Braun & Clarke, 2019). With the repetitive nature of procedures in mind, we present a view of how our analysis was conducted. First, the primary author immersed herself in the data through listening to the audio files for each session, re-listening while editing the pre-transcribed transcript, and re-listening and re-reading once again. This process of data immersion was repeated as much as necessary to root the researcher in the data.

Next, the first author proceeded to make reflections of what she heard and saw in the margins of the transcripts. These reflections informed the initial raw codes that were later entered into a codebook and refined over time as the author gained exposure to more data. While a code book is not typically promoted with (reflexive) TA practices (Braun & Clarke, 2020), a code book was utilized by the first author to assist her comprehension of data, to help maintain a record of codes that were found in the data thus far, to visually assist in code collapsing and merging, and to also aid in data re-immersion after periods of retreat. After reflections were made on each transcript, transcripts were then transferred to a qualitative coding software (i.e., ATLAS.ti 8 Windows) for further coding and analysis. Coding was focused on both explicit (semantic) and implicit (latent) cultural markers that arose in therapy sessions. Using the researcher as a resource, information gleaned from the journal entries of the first author helped to shine a light on power dynamics present in the therapeutic content. Presence of power dynamics in first session conversations cued the researcher to identities the client and/or therapist brought into the therapeutic space, further illuminating potential cultural conversations. Consultation was also enacted between the first author, second author, and research lab as another form of reflexive practice.

Drawing from the continuum of inductive and deductive practices, we were also able to identify codes that, subsequently, led to theme generation (Braun & Clarke, 2006; Braun & Clarke, 2019; Braun & Clarke, 2020). Inductive data was grounded in the conversations between clients and their therapists. Deductively, theories of feminism and multiculturalism informed power dynamics that were not only showing up in the content between client and therapist, but also within the therapeutic space. As mentioned above, recognizing power dynamics in therapy sessions, such as privilege and oppression, helped cue the researcher to cultural content that could be explored. Codes were refined, deleted, or collapsed as larger, overarching themes were identified. This process of code and theme formation, too, was repetitive in nature until the researchers identified themes, or patterns of meaning, across the data. The final step involved report writing, in which themes are woven together to tell a coherent narrative of patterned meaning across the emergence of cultural opportunities examined in this study.

Results

In our analysis, we identified four themes related to the types of conversations therapists and clients had, which led to cultural opportunities. We conceptualized each of these conversations as separate “windowpanes,” which form a larger “window of cultural opportunity” from which therapists (and clients) can take throughout a session to deepen understanding of clients’ cultural identities. These include windowpanes of: (a) feeling, (b) identity meaning, (c) relational community context, and (d) symptom (Figure 1). These panes also provide options through which therapists and clients can explore how a clients’ cultural background may be linked to their presenting concerns.

Figure 1.

Window of Opportunity

Note. A representation of a “window of opportunity,” or cultural opportunity, and the unique “panes” a therapist and client may gaze through to explore salient cultural content that arise in a counseling session.

We also identified 3 themes that captured how cultural opportunities emerged, or the process (e.g., paralinguistics; how a therapist directs a session) through which cultural conversations were addressed (or not) within sessions. Continuing with the metaphor of “window of opportunity,” these themes included: (a) look out the same window: using client’s language to explore culture, (b) glance out the window: minimal or no exploration of cultural opportunity, and (c) keep the window open: fluidity of cultural opportunities.

Windowpane of Feeling

In several counseling sessions, therapists engaged in cultural opportunities by first reflecting upon the feelings their client expressed. They then illuminated aspects of clients’ cultural background to better understand how these core emotions might be tied to salient social identities. For example, Linda, a client who identified as a white, Christian, full-time student, and working mom, reported distress related to not being able to spend enough time with her child. In this session, Angelita, a therapist of color, responds to Linda’s sadness, reflects other potential feelings, and ties in societal expectations related to Linda’s identity as a mother.

Linda (C): [crying] And also, like honestly, the times I’m most sad is when I just like think about my baby and that she’s, she’s just playing without me. When I think that, like if she does something, it’s my fault, you know? … And so that, [sniffs] that makes me the most sad. [cries] Just thinking about her, and like what if I lost her, or, you know? …

Angelita (T): …I almost wonder if there’s some feelings of guilt there.¹

Linda (C): … I don’t know, like I don’t like the term “mom guilt.” ‘Cause it, I dunno, I just don’t like it. Even though it’s a good description of what’s, you know, what happens to moms, but I just, I just, I don’t know. I do feel guilty, I feel sad. Like that’s the main thing I feel is sad. Like I don’t, I can’t do both, you know?

Angelita (T): …Yeah, um, yeah, ‘cause you see it a lot, culturally…they say, like either you’re a really good mom, or you can be, um, highly achieving and like do a career…But somehow you can’t have both…Which doesn’t sound all that right to me.

Angelita looked through the windowpane of feeling to explore and normalize Linda’s emotional experience as a woman and a mother, including her sadness and frustration with the societal pressures placed on women. Angelita ties in Linda’s emotions while taking into consideration how they may be informed by gender.

Windowpane of Identity Meaning

Counselors in our study also explicitly explored clients’ social identities, specifically how clients’ positionality (e.g., gender, class, race) influenced their daily experiences. For example, in their first session together, Hattie (white therapist) and Amrish (racial-ethnic minority and religious man) explore his life roles and its associated pressures. Below, they explore Amrish’s role in his family and connect this concern to his racial-ethnic, class, gender, and religious identities:

Amrish (C): …My father’s not well educated, so forget sciences. Um, he’s- he’s more physically inclined than academically inclined all together, so he thinks that a body’s more necessary than a brain, and I mean, obviously, so…

Hattie (T): What’s this mean?

The therapist uses an open-ended question to explore more of what these various identities, including physicality, mean to him. Following this question, the client expands more.

Amrish (C): I’m skinny-lanky. So not big, not buff, not small. I’m not- not able to do the- the physical labor that he thinks is required or to be successful in life. And so, I don’t talk to him at all anyway.

Hattie continues to utilize open-ended questions regarding Amrish’s meaning of being “an academic,” differences in his relationship with faith compared to his father’s, until ultimately Amrish shares what being Indian means to him.

Windowpane of Relational Community Context

This code highlights a person’s significant social relationships as an entry point to better understand a person’s community and cultural background. The interaction below involves Jane, a white therapist and Peter, an Asian man with no religious affiliation. In this session, Peter talks about his difficulty with establishing relationships in the U.S. as an international student, which opens a window for deeper discussion of what community and culture mean to him.

Peter (C): Like, uh, especially around here. I have some really good friends back in [Country], but right now, like here, I feel like…it is kind of, like, pointless for me to make any friends, because I’m never gonna receive any reply from any person…

Jane (T): …And so you said you have, um, many friends back in [Country]? Is that correct? Is that what you said?

Peter (C): …Yeah, that live in [Country].

Jane (T): …Gotcha, okay…where did you grow up?

Jane’s question of where Peter grew up led to more exploration of Peter’s social network and the importance of location. Further, she asks the question “Where did you grow up?” which does not assume Peter is from a country outside of the United States and leads into a richer description of his cultural experiences.

Peter (C): I, uh, I was born in [Country]…Uh, lived there, I lived there until the age of 15….Then I went to a high school in [State]…Studied for three years, graduated, then came here… I mainly feel this after I came to college, honestly.

Jane (T): Oh, okay. Here in [City] most- mostly?

Peter (C): Yeah.

Through exploration of Peter’s relational history, Jane also begins to learn more about his cultural adjustment since attending university in a predominantly white state.

Windowpane of Symptom

For several dyads, asking about mental health symptoms provided cultural opportunities. By discussing clients’ previous diagnoses, presenting concerns, and ways of coping, therapists were able to learn more about how culture informed the client’s symptomatology. In this first meeting, Han (therapist), a Person of Color met with Aguilar (client) and their partner Lindsay who was a guest in this session. Aguilar identified as a gender non-binary Person of Color with no religious affiliation. Aguilar disclosed having a prescription for their mental health diagnoses and worried they would become reliant on medication.

Aguilar (C): So usually before, I was able to at least control myself a little bit without the medication ‘cause I don’t like taking medication at all if it’s not necessary. Like I’ll do it if it’s necessary. But if it’s like a headache or something, I’ll just… deal with it. Um, but yeah, I’ve been relying on that a lot… I think it mostly has to do with my mom too because she doesn’t like believe… much in… like mental illnesses… Like she always tells me, like, “Try to control yourself.”

Han (T): We get that message from like our family, from our culture, from society…Uh, we get it everywhere. And so like we internalize that shit all the time…And to go against that feels weird…It feels kind of like it’s going against second nature.

As the session continued, Han and Aguilar explored some of the socially oppressive messages related to mental health, which then provided another opportunity to counter oppressive messages Aguilar received related to their sexual and gender identity.

Look Out the Same Window: Using Client’s Language to Explore Culture

Across sessions, most therapists use the same language as their clients when responding to cultural material. In the example provided, Nour, a racial-ethnic minority, and client, Peyton, a white, gender non-binary person with no religious affiliation, discuss how Peyton’s gender identity influences their career aspirations.

Peyton (C): (laughs) I just thought, like, at the beginning of last semester, I knew what I wanted to do. I could imagine myself as a doctor 10 years in the future. I’d be like a woman doctor…I knew that and then I was like, I don’t know what I want to be anymore…

Nour (T): Now, it’s just uncertain.

Peyton (C): …See the thing about being a doctor… like Dr. [Name], you don’t know, like there’s a gender anonymity in that. It doesn’t matter on paper and when people talk to you; it doesn’t matter. And then when you’re a teacher you’re like-

Nour (T): : I have to be Mr. or Miss, right? There’s no currently gender neutral option.

In the interaction above, Nour homes in on not only Peyton’s uncertainty around career aspirations, but also the use of language around their gender identity. Nour validates Peyton’s experience while also joining them in challenging binary approaches to titles, such as Mr. or Ms.

Glance Out the Window: Minimal Exploration of Cultural Opportunity

Another process that was observed between therapist and client were moments where counseling dyads touched briefly on a cultural topic but did not explore these cultural topics in depth. These instances were typically carried and led by the client as the therapist provided minimal encouragers. In other instances, the therapist asked questions regarding what the client shared, however does not deepen our understanding of the client’s lived experience with their cultural identities. In the excerpt below, Lazaro, a therapist of color, and Cheryl, a white woman who identifies as a member of the Church of Jesus Christ of Latter-day Saints (LDS) discuss Cheryl’s experience of anxiety since returning early from her mission. As they explore the timeline of recent events and associated levels of anxiety, Lazaro asks about Cheryl’s friends and their affiliation with the church. After learning that Cheryl’s friends have already completed their mission, Cheryl explains her reasoning for waiting.

Cheryl (C): So, ‘cause when I left on my mission, I was twenty one. Girls can leave when they’re nineteen, and guys can leave when they’re eighteen. So on the mission, I was one of the older missionaries.

Lazaro (T): Okay. Was it something that wasn’t what you were thinking of?

Cheryl (C): …Um, at first like growing up, like a little bit. And then when I was a teenager, I’m like, ‘No, I don’t want to go, I want to focus on my career.’ And then I just had this moment where I’m like, ‘No, this is something I want, this is something I believe.’

Lazaro (T): …Okay. Sounds good. Um, so was; did you have any other type of counseling before then?

At this point, Lazaro briefly gathered information about contributing factors to the timing of Cheryl’s mission and how that was reflected in her being one of the “older missionaries.” It seems Lazaro glanced through a cultural windowpane of identity meaning but did not explore further; instead, the therapist moved into discussion about therapy and symptom history without a cultural focus. In contrast to her verbose response regarding her cultural background, Cheryl’s responses in the remainder of this transcript were sparse.

Keeping the Window Open: Fluidity of Cultural Opportunities

Across a number of sessions, we observed cultural opportunities emerge at various points within a conversation. At times, counselors used these moments to explore cultural aspects of the client’s presenting issues. However, there were numerous instances in which they were not addressed in the moment; instead, the cultural opportunity was picked up later in a session, highlighting the fluid nature of cultural conversations.

The fluidity of cultural opportunities is demonstrated in a session with Lee a racial-ethnic minority and client, Kevin, who identified as an Asian man with a non-Christian religious affiliation. Within the first 5 minutes of the session, Kevin shares with Lee that he struggles with romantic relationships and recently ended a relationship with another man. After Kevin’s disclosure, Lee first explores Kevin’s experience as an international student struggling to find a sense of belonging, both in his country of origin and the United States. However, it is not until the middle of the session when Lee invites Kevin to talk about his intersecting identities as a gay Asian man and the potential connection with his feelings of inadequacy and unacceptance.

Kevin (C): So yeah, like I feel like I’m stuck…because like in the morning I wake up and then I would be very confident, you know…I don’t need…acceptance…but at the end of the day I go home and I just feel, just feel [I’m] being left behind, you know? Just feel very lonely…

Lee (T): Yeah, I feel like it sounds like there’s a lot of things going on that kind of makes it hard for you to find that acceptance piece, and um, feel adequate…whether it’s from your family or from the people here in the program, or just this country in general. Especially with the political climate right now, it can feel really isolating, can feel really lonely. And I imagine also being a gay Asian man too feels pretty lonely too…Even though we want to say like, “Screw other people and their acceptance, we know what we’re capable of, and we have skills,” it’s still hurts…’Cause we want to be accepted.

Lee formulated a tailored response that was culturally informed to reflect Kevin’s experience of loneliness. Lee demonstrated that Kevin’s identities are important and permissible to explore as this dyad continued to discuss both Kevin’s presenting concerns and his cultural identities throughout the remainder of session.

Discussion

The present study utilized (reflexive) thematic analysis to examine cultural opportunities that emerge in first therapy sessions. According to MCO literature, cultural opportunities emerge often in therapy (Davis et al., 2018) and are mentions of cultural content that provide an opportunity to explore a salient aspect of the client’s identity (Owen et al., 2016). A characteristic feature of the cultural opportunity is that the exploration emerges naturally, not impeding the flow of what the client is sharing. Therefore, cultural topics may not always be addressed explicitly, and are woven into session when appropriate. To better understand the phenomenon of cultural opportunities, we sought to investigate how therapists engage in cultural conversations, how these opportunities emerge in the first counseling session, and how cultural conversations are influenced by the type of cultural opportunities.

Windowpanes of Opportunity

First, the various windowpanes of opportunity (i.e., feeling, identity, relational community context, symptom) offered a multifaceted approach to leveraging cultural opportunities in session through exploring varying cultural aspects of client content. Our study found that all clients shared information about relational others, unveiling the windowpane of relational community context to their therapists. Several theorists highlight the importance of understanding a client’s presenting concerns within the context of their relationships and other social systems (e.g., feminist multicultural therapy; Brown, 1990; Morrow & Hawxhurst, 1998). Thus, the way in which we talk about ourselves may also include those who are important to us (e.g., relational cultural theory; Jordan et al., 1991). Therapists can reflect clients’ feelings and focus on the individual self, however, emotions and who clients are set the stage for these cultural topics to appear (windowpane of feeling). In contrast to the above, windowpane of symptom appeared in only about half of the sessions. The connection between symptom and cultural information may have been approached similarly to a clinical setting, in which symptomatology is typically discussed without cultural context (Chang et al., 2012), despite useful examples in the literature like the Cultural Formulation Interview (CFI) included in the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5; American Psychiatric Association, 2013).

Broaching Cultural Opportunities in the First Session

Our findings also suggest that clients bring up cultural content as early as the first session and seem willing to talk about cultural identities when invited to do so. Engaging in cultural discussions often yields valuable information to inform the client’s presenting concerns and subsequent treatment and outcomes. For instance, evidence suggests that therapists’ perceived level of multicultural competency by their clients is positively correlated with the working alliance (Constantine, 2007; Fuertes et al., 2006; Owen et al., 2012), which in turn is associated with treatment outcomes (Anderson et al., 2019; Kegel & Fluckiger, 2015). Further, a narrative analysis of first psychotherapy sessions indicated that a positive treatment outcome was linked to therapists’ interventions that prioritized the importance of understanding clients’ cultural perspectives whereas more negative treatment outcomes were tied to missed cultural opportunities (e.g., not following up on important cultural identities and experiences shared by the client) (Tsang et al., 2011). Therefore, welcoming client identities and engaging in cultural conversations in the therapy room may positively influence the working alliance and subsequent treatment outcomes.

Moreover, research suggests different reasons for why cultural opportunities may be missed in session. For example, research on cultural concealment in counseling suggests clients who consciously withhold aspects of their cultural identities do not improve as much as those who willingly disclose cultural content with their therapists (Drinane et al., 2018). Thus, if therapists are cognizant of cultural markers and intentionally attend to them early on, this may in turn influence the outcome of therapy. Furthermore, windows of opportunity for cultural conversations can be prematurely foreclosed (e.g., unilateral termination) when clients do not perceive their therapists to be comfortable in having discussions related to their cultural background or social identities (see Owen et al., 2017).

How Therapists Interacted with Windows of Cultural Opportunity

Our study also led to a clearer understanding of how therapists engage in cultural conversations. This did not always involve the explicit use of words or questions tied to culture (e.g., tell me about your ethnic background). Rather, it was the way in which therapists attended (or did not attend) to content, integrated broad societal messages, allowed for the fluidity of conversation, reflected clients’ cultural language, or at times did not seem to pick up on cultural opportunities. The act of attending to aspects of client content (e.g., affective, behavioral, cognitive) is a core counseling skill that is commonly taught across training level programs (Ivey et al., 2018), but may leave cultural content unexamined (e.g., glancing out the window). Often conceptualized as a supplement to core skill development is the building of multicultural counseling competencies (cultural knowledge, skills, and awareness) through focusing interventions on cultural components of client content (Ivey et al., 2018; Sue et al., 1992). As suggested by the literature, how comfortable a client perceives their therapist to be in having cultural conversations holds implications for the working alliance and client outcome (Owen et al., 2011). Our study found several possible ways in which therapists can attend to cultural content through both the type of cultural conversation opener (e.g., windowpane of feeling) as well as how they attend to what the client brings up (e.g., looking out the same windowpane).

Another noteworthy finding was related to the fluidity of conversations and therapists’ artful ability to bring back a meaningful area of cultural exploration after the first cultural opportunity arose. This skill is commonly referred to as an intentional focus on cultural environmental context and is often taught in multicultural counseling courses (Ivey et al., 2018). The fluidity theme suggests that there is no defined time limit on when exploration of a cultural window can occur; we can always come back to it.

Our findings echo some of the current MCO literature on how cultural conversations are occurring in psychotherapy. For instance, work done by Gundel and colleagues (2020) also found that a therapist and her client seemingly looked through the same window, using similar language when discussing the client’s cultural background. Perez and colleagues (2019b) similarly found that bilingual clients described positive experiences with therapists who took a bilingual orientation, or an approach that demonstrated comfort, such as restating what their clients said in the language they used.

Implications for Training & Supervision

As a vital component of training, attending to cultural content in a counseling session allows therapists to gather more information around the client’s values, beliefs, and a sense of who they are. Gathering this information can then inform how therapists work with the client and conceptualize their client’s presenting concerns in ways that can be more congruent with the cultural client’s experience. In this study, we found that cultural opportunities are not only abundant, but can be addressed at various points within a session.

For many emerging therapists (or experienced therapists), however, the idea of addressing cultural content in the first session can be somewhat daunting or uncomfortable. In general, people who have been raised in the U.S. with dominant social identities (White, heterosexual, Christian) have not been socialized to address topics of race or cultural differences head on, tacitly avoiding the ubiquity of Whiteness and invariably perpetuating the status quo (Bartoli et al., 2015). However, our study indicates that it behooves all therapists to engage in cultural conversations early on, recognizing that clinical issues clients bring in are potentially expressions of larger systemic and cultural inequities (Bartoli et al., 2015). Thus, a recommendation for training programs and supervisors is to provide early and frequent opportunities for therapists-in-training to practice. Day-Vines (2018) asserts it’s about “getting comfortable with discomfort” and promotes the practice of broaching. Broaching behavior “refers to a consistent and ongoing attitude of openness with a genuine commitment by the counselor to continually invite the client to explore issues of diversity” (Day-Vines et al., 2007, p. 402). It is important to let clients know right away that the therapy space is one that allows for “new” and more holistic ways of talking about a client’s presenting concerns.

Limitations & Recommendations for Future Research

There were several limitations to the current study. First, our study took place at a university counseling center in a predominately white Mountain West State, where cultural values are strongly influenced by the Church of Jesus Christ of Latter-day Saints. Therefore, how cultural opportunities presented themselves and subsequent dyadic interactions may look differently in other contexts (e.g., community mental health, other regions of the U.S.). Second, we were limited by the type of demographics reported by clients and therapists; we also redacted some of the identifiers of therapist and clients to maintain confidentiality of our participants. Thus, our study was limited in its ability to account for varying experiences related to saliency or intersecting identities (race, class, gender, etc.). Third, we were unable to view the video recordings of sessions, potentially limiting our ability to capture the richness of non-verbal interactions between clients and their therapist. Fourth, due to the integral components of the method used (i.e., [reflexive] thematic analysis), such as positionality and subjectivities, there is a potentiality for our biases to influence the data (Braun & Clarke, 2006; Braun & Clarke, 2020). While we did our best to attend to biases through reflexive practices, the analysis we present is undoubtedly shaped by who we are as researchers and as subjective human beings. Finally, due to the observational nature of this study, we were unable to interview participants to better understand their experiences, how they felt, or discern intentionality around how they navigated cultural opportunities in the sessions we examined. Therefore, we are not able to draw interpretive conclusions regarding reasons for interventions the therapist used.

In addition to addressing the limitations above, we suggest future research examine the effects of using different approaches to leverage cultural opportunities in session and its effects on cultural deepening. We also suggest using mixed-methods studies (e.g., include MCO measures) to better understand how therapists’ self-report of cultural comfort, cultural opportunities and cultural humility is reflected in session and are predictive of client outcomes. A final suggestion for future research is to consider the cultural identities of therapists when investigating cultural opportunities. For instance, Moon and Sandage (2019) explain that when we situate the therapist in context, particularly therapists of color (TOC), we widen our lens to see the broader context which encapsulates oppression, such as ongoing racism. Accordingly, it is important to consider the oppressive experiences of TOC when examining MCO factors, such as if and how they are engaging in cultural conversations (Moon & Sandage, 2019).

In conclusion, while there are several limitations to the current study, we believe that there is valuable information here for psychologists across levels of development. Specifically, our findings highlight that not only are cultural opportunities commonly found in psychotherapy, they are also found as early as the first psychotherapy session. Our findings also provide several examples as to how cultural opportunities may emerge in session (e.g., windowpane of feeling), as well as varying ways they can be engaged with (e.g., look through the same window). We believe our findings can inform training, practice, and research for those interested in attuning to and exploring cultural content in psychotherapy.

Data used for the current study is from a larger ongoing national study (Digital Exploration of Psychotherapy; DEPTH).

Clinical Impact Statement:

Question:

How do clients and therapists engage in cultural conversations? Findings: We found four ways that cultural opportunities emerge in session and three ways they are engaged with. Meaning: Therapists and clients can explore and better understand clients’ cultural backgrounds in a variety of ways. Next Steps: Future research should examine the effects of using different approaches to utilize cultural opportunities for cultural deepening, as well as how therapists’ self-reported MCO ratings are reflected in session.